MEDICARE: JEREMY SHULMAN

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	1223P0300X	Periodontics	0401002488	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	147713	OTHER	VA	ANTHEM PROVIDER NUMBER
2	231794	OTHER	VA	CIGNA DENTAL
3	177146	OTHER	VA	UNITED CONCORDIA DENTAL
4	C08502040	OTHER	VA	SUBMITTER ID

General Provider Information

NPI Number	:	1871768390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEREMY SHULMAN

Provider Business Mailing Address
First Line	:	2061 THOMAS BISHOP LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-1129
Country	:	US
Telephone Number	:	757-496-8070
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 FIRST COLONIAL RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2263
Country	:	US
Telephone Number	:	757-496-8070
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ROCHELLE DENISE CUBITT
Credential	:
Telephone Number	:	757-496-8070

Provider Enumeration Date	:	04/25/2008
Last Update Date	:	11/03/2011

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Directions to “JEREMY SHULMAN ” Practice Location

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