MEDICARE: MEDICAL PRACTICE, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	0101023718	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	110138225	OTHER	VA	MEDICARE-RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	461191	OTHER	VA	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	12090	OTHER	VA	OPTIMA HEALTH

General Provider Information

NPI Number	:	1609938505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL PRACTICE, LTD.

Provider Business Mailing Address
First Line	:	710 LIBERTY ST
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23324-2637
Country	:	US
Telephone Number	:	757-543-6861
Fax Number	:	757-543-4082

Provider Business Practice Location Address
First Line	:	710 LIBERTY ST
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23324-2637
Country	:	US
Telephone Number	:	757-543-6861
Fax Number	:	757-543-4082

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DHARMESH K SHAH
Credential	:	M.D.
Telephone Number	:	757-543-6861

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	09/29/2014

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Directions to “MEDICAL PRACTICE, LTD. ” Practice Location

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