Provider Demographics
NPI:1285064758
Name:SHADY GROVE PEDIATRICS, PC
Entity type:Organization
Organization Name:SHADY GROVE PEDIATRICS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAVELSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-775-6891
Mailing Address - Street 1:11127 JOURNAL PKWY
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-3468
Mailing Address - Country:US
Mailing Address - Phone:540-775-6891
Mailing Address - Fax:540-775-6894
Practice Address - Street 1:11127 JOURNAL PKWY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-3468
Practice Address - Country:US
Practice Address - Phone:540-775-6891
Practice Address - Fax:540-775-6894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty