Provider Demographics
NPI:1912235268
Name:SHANAHAN RHEUMATOLOGY AND IMMUNOTHERAPY, PLLC
Entity type:Organization
Organization Name:SHANAHAN RHEUMATOLOGY AND IMMUNOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:COUTURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-772-8500
Mailing Address - Street 1:10208 CERNY STREET
Mailing Address - Street 2:WAKE MED BRIER CREEK MEDICAL PARK
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617
Mailing Address - Country:US
Mailing Address - Phone:919-949-2228
Mailing Address - Fax:
Practice Address - Street 1:10208 CERNY STREET
Practice Address - Street 2:WAKE MED BRIER CREEK MEDICAL PARK
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617
Practice Address - Country:US
Practice Address - Phone:919-949-2228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801767207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890138JMedicaid
NC890138JMedicaid