Basic Information
| Provider Information | |||||||||
| NPI: | 1578502142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIVERS | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575944006 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 OLD DENBIGH BLVD STE 1020A | ||||||||
| Address2: | RIVERSIDE LIFELONG HEALTH & AGING SERVICES | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236022017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578752009 | ||||||||
| FaxNumber: | 7573691042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101050193 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1578502142 | 05 | VA | MEDICAID |