Provider Demographics
NPI:1316921828
Name:SHADDUCK, PHILLIP PRICE (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:PRICE
Last Name:SHADDUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WILLIAM PENN PLZ
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2150
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:919-313-1276
Practice Address - Street 1:120 WILLIAM PENN PLZ
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2150
Practice Address - Country:US
Practice Address - Phone:919-220-5255
Practice Address - Fax:919-313-1276
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93-00312208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8975341Medicaid
NC75341OtherBCBS NC
NC75341OtherBCBS NC
NC8975341Medicaid