Healthcare Provider Details

I. General information

NPI: 1518089366
Provider Name (Legal Business Name): SHENANDOAH PREVENTIVE MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S LOUISIANA AVE
MARTINSBURG WV
25401-2037
US

IV. Provider business mailing address

215 S LOUISIANA AVE
MARTINSBURG WV
25401-2037
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-3335
  • Fax: 304-267-5557
Mailing address:
  • Phone: 304-263-3335
  • Fax: 304-267-5557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number1000
License Number StateWV

VIII. Authorized Official

Name: DR. JOHN ALEXANDER BURGESS V
Title or Position: PRESIDENT
Credential: D.O.
Phone: 304-263-3335