Healthcare Provider Details

I. General information

NPI: 1053842468
Provider Name (Legal Business Name): SHENANDOAH MEMORIAL HOSPITAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5173 MAIN ST
MOUNT JACKSON VA
22842-9513
US

IV. Provider business mailing address

5173 MAIN ST
MOUNT JACKSON VA
22842-9513
US

V. Phone/Fax

Practice location:
  • Phone: 540-459-1350
  • Fax: 540-459-1351
Mailing address:
  • Phone: 540-459-1350
  • Fax: 540-459-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RENEE Y BAKER
Title or Position: MANGER, INSURANCE CREDENTIALING
Credential:
Phone: 540-536-0231