Healthcare Provider Details

I. General information

NPI: 1194867952
Provider Name (Legal Business Name): W. ERIC SHRADER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

986 BEN BOLT AVE
TAZEWELL VA
24651
US

IV. Provider business mailing address

PO BOX 309
TAZEWELL VA
24651-0309
US

V. Phone/Fax

Practice location:
  • Phone: 276-979-1323
  • Fax: 276-979-9123
Mailing address:
  • Phone: 276-979-1323
  • Fax: 276-979-9123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101037561
License Number StateVA

VIII. Authorized Official

Name: DR. W ERIC SHRADER
Title or Position: OWNER
Credential: M.D.
Phone: 276-979-1323