Healthcare Provider Details

I. General information

NPI: 1285064758
Provider Name (Legal Business Name): SHADY GROVE PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11127 JOURNAL PKWY
KING GEORGE VA
22485-3468
US

IV. Provider business mailing address

11127 JOURNAL PKWY
KING GEORGE VA
22485-3468
US

V. Phone/Fax

Practice location:
  • Phone: 540-775-6891
  • Fax: 540-775-6894
Mailing address:
  • Phone: 540-775-6891
  • Fax: 540-775-6894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ILYA ZAVELSKY
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 540-775-6891