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General NPI Number Information
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NPI Number | 1285064758
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Entity Type | Organization
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Legal Business Name | SHADY GROVE PEDIATRICS, PC
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Dates
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Enumeration Date | 11/20/2013
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Last Update Date | 11/20/2013
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Provider Practice Location Address
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Address Line | 11127 JOURNAL PKWY
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City | KING GEORGE
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State | VA
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Zip | 22485-3468
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Country | US
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Telephone | 540-775-6891
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Fax | 540-775-6894
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Provider Business Mailing Address
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Address Line | 11127 JOURNAL PKWY
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City | KING GEORGE
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State | VA
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Zip | 22485-3468
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Country | US
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Telephone | 540-775-6891
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Fax | 540-775-6894
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | ILYA ZAVELSKY
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Credential | MD
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Telephone | 540-775-6891
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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