=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639421936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHADY GROVE FERTILITY CENTER OF PA PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2012
-----------------------------------------------------
Last Update Date | 07/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 735 CHESTERBROOK BLVD SUITE 100
-----------------------------------------------------
City | CHESTERBROOK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-981-6000
-----------------------------------------------------
Fax | 855-437-5785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9600 BLACKWELL ROAD SUITE 500
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-340-1188
-----------------------------------------------------
Fax | 855-716-1603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE MANAGING DIRECTOR
-----------------------------------------------------
Name | VICKI GERBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-545-1248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 022789A
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------