Healthcare Provider Details

I. General information

NPI: 1679575021
Provider Name (Legal Business Name): SHIRLEY JOHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHIRLEY JOHN KAITHACKACHALIL MD

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NEW SALEM ROAD SUITE 116
UNIONTOWN PA
15401
US

IV. Provider business mailing address

100 NEW SALEM ROAD SUITE 116
UNIONTOWN PA
15401
US

V. Phone/Fax

Practice location:
  • Phone: 724-437-0729
  • Fax: 724-437-2761
Mailing address:
  • Phone: 724-437-0729
  • Fax: 724-437-2761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD068587L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: