Healthcare Provider Details

I. General information

NPI: 1548224801
Provider Name (Legal Business Name): KEVIN G SHORTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 HIGH ST
PORTSMOUTH VA
23707-3236
US

IV. Provider business mailing address

7007 HARBOUR VIEW BLVD SUITE 108
SUFFOLK VA
23435-3657
US

V. Phone/Fax

Practice location:
  • Phone: 757-398-2222
  • Fax: 757-398-2020
Mailing address:
  • Phone: 757-215-2784
  • Fax: 757-215-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number232213
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number232213
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101246279
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberTL3674
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: