Provider Demographics
NPI:1861704926
Name:DR. PHILLIP Y SHOU PC
Entity type:Organization
Organization Name:DR. PHILLIP Y SHOU PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:Y
Authorized Official - Last Name:SHOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-526-3821
Mailing Address - Street 1:2801 BOULEVARD
Mailing Address - Street 2:SUITE D
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2323
Mailing Address - Country:US
Mailing Address - Phone:804-526-3821
Mailing Address - Fax:804-526-6065
Practice Address - Street 1:2801 BOULEVARD
Practice Address - Street 2:SUITE D
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2323
Practice Address - Country:US
Practice Address - Phone:804-526-3821
Practice Address - Fax:804-526-6065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041517208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6751300Medicaid