NPIMap

Organization Active NPI

Shady Grove Dermatology

  • Specialist
  • Rockville, MD
National Provider Identifier
1790177210
Registry record updated Mar 5, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
D0028453 Issued in MD
Legal business name
SHADY GROVE DERMATOLOGY
Practice address
15245 Shady Grove Rd
Suite 370
Rockville, MD 20850-3222
Phone
(240) 246-7417
NPI assigned
Feb 20, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 5, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Sandee Hall Davidson
Title
Business Consultant
Phone
(240) 246-7417

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X D0028453 MD Primary
Medical Specialty Clinic/Center 261QM2500X

Addresses

Primary practice location

15245 Shady Grove Rd
Suite 370
Rockville, MD 20850-3222

Mailing address

15245 Shady Grove Rd
Suite 370
Rockville, MD 20850-3222
Phone (240) 246-7417

Other names 1

  • Shady Grove Dermatology, LLC Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in DC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150616000078 DC Part B Supplier - Clinic/Group Practice 0042521205 Receives reassigned benefits from 5 practitioners
Practice locations: Rockville, MD

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1424390400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709596800000",
    "number": "1790177210",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15245 SHADY GROVE RD",
            "address_2": "SUITE 370",
            "city": "ROCKVILLE",
            "state": "MD",
            "postal_code": "208503222",
            "telephone_number": "240-246-7417"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15245 SHADY GROVE RD",
            "address_2": "SUITE 370",
            "city": "ROCKVILLE",
            "state": "MD",
            "postal_code": "208503222",
            "telephone_number": "240-246-7417"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADY GROVE DERMATOLOGY",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-02-20",
        "last_updated": "2024-03-05",
        "certification_date": "2024-02-26",
        "status": "A",
        "authorized_official_last_name": "DAVIDSON",
        "authorized_official_first_name": "SANDEE",
        "authorized_official_middle_name": "HALL",
        "authorized_official_title_or_position": "BUSINESS CONSULTANT",
        "authorized_official_telephone_number": "240-246-7417",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "MD",
            "license": "D0028453",
            "primary": true
        },
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shady Grove Dermatology, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Rockville, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.