Provider Demographics
NPI:1306083324
Name:SHIVASHANKER PC
Entity type:Organization
Organization Name:SHIVASHANKER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:FLOURNOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-579-2188
Mailing Address - Street 1:406 FOREST PKWY
Mailing Address - Street 2:STE A
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2190
Mailing Address - Country:US
Mailing Address - Phone:404-361-3100
Mailing Address - Fax:404-361-3141
Practice Address - Street 1:7695 HIGHPOINT DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:404-361-3100
Practice Address - Fax:404-361-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034881208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000477287KMedicaid
GA000477287KMedicaid