SHADY GROVE DERMATOLOGY
NPI 1790177210
Specialist in Rockville, MD
About Shady Grove Dermatology NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
SHADY GROVE DERMATOLOGY (NPI 1790177210), doing business as Shady Grove Dermatology, Llc, is a healthcare organization registered as a specialist in Rockville, Maryland and active in the NPI registry since February 2015. The organization holds a CLIA Certificate of Compliance certificate valid through December 1, 2027 and lists Sandee Hall Davidson, Business Consultant, as its authorized official.
NPPES Registry Identity
Specialties & Licenses 2
Other Names 1
Group Practice 1
Medicare Participation & PECOS CMS
Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
Shady Grove Dermatology is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Clinicians Billing Medicare Through This Organization
4Medicare enrollment records show 4 clinicians reassign Medicare billing to Shady Grove Dermatology, which bills Medicare for the services they deliver. Of these, 3 practice at this address and 4 within 10 miles. They are listed nearest first.
Clinicians, nearest first (4)
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
CLIA Laboratory Certificates CMS CLIA
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate of Compliance 21D2112261
Shady Grove Dermatology, LLC · Rockville, MDFrequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Shady Grove Dermatology's NPI number?
The NPI number for Shady Grove Dermatology is 1790177210. It was assigned to this organization in the NPPES registry on February 20, 2015. The provider was formerly known as Shady Grove Dermatology, LLC.
Where is Shady Grove Dermatology located?
Shady Grove Dermatology is located at 15245 Shady Grove Rd Suite 370, Rockville, MD 20850. The listed phone number is (240) 246-7417.
What is Shady Grove Dermatology's specialty?
The primary specialty registered for this NPI is Specialist with taxonomy code 174400000X.
Is Shady Grove Dermatology enrolled in Medicare?
Yes. Shady Grove Dermatology is registered in the Medicare PECOS enrollment system.
How many clinicians bill Medicare through Shady Grove Dermatology?
According to the CMS Revalidation Reassignment List (October 2026 release), 4 clinicians in 2 Medicare specialties reassign their Medicare billing to Shady Grove Dermatology. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. The largest specialties are Dermatology (3) and Nurse Practitioner (1). Of these, 3 practice at this address and 4 within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Does Shady Grove Dermatology hold a CLIA laboratory certificate?
Yes. A Certificate of Compliance (number 21D2112261) is associated with this NPI, valid through December 1, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.
When was this NPI record last updated?
The NPPES record for Shady Grove Dermatology was last updated on March 5, 2024. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 2 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Shady Grove Dermatology · NPI 1790177210
Specialist organization in Rockville, Maryland. Organization record, active in the CMS NPPES registry since February 20, 2015.
## Identity
- **NPI:** 1790177210 (Entity type: Organization)
- **Enumerated:** February 20, 2015
- **Primary specialty:** Specialist · taxonomy 174400000X
- **Organization subpart:** No
- **Authorized official:** Sandee Davidson, BUSINESS CONSULTANT
## Practice location
- **Address:** 15245 SHADY GROVE RD, SUITE 370, Rockville, MD 20850-3222
- **Phone:** (240) 246-7417
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Clinicians billing through this organization:** 4 clinicians in 2 Medicare specialties reassign Medicare billing to this organization (form CMS-855R); largest: Dermatology (3), Nurse Practitioner (1); 3 practice at this address and 4 within 10 miles · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** March 5, 2024
- **CLIA laboratory certificates:** 1 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1790177210) · Data from the CMS NPPES public registry.