=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518089366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHENANDOAH PREVENTIVE MEDICINE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 S LOUISIANA AVE
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-3335
-----------------------------------------------------
Fax | 304-267-5557
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 S LOUISIANA AVE
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-3335
-----------------------------------------------------
Fax | 304-267-5557
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN ALEXANDER BURGESS V
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 304-263-3335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204D00000X
-----------------------------------------------------
Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
-----------------------------------------------------
License Number | 1000
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------