Provider Demographics
NPI:1316952849
Name:SHILOH MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:SHILOH MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLO PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-733-7560
Mailing Address - Street 1:1029 N PEACHTREE PKWY
Mailing Address - Street 2:STE#203
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4210
Mailing Address - Country:US
Mailing Address - Phone:770-733-7560
Mailing Address - Fax:
Practice Address - Street 1:1029 N PEACHTREE PKWY
Practice Address - Street 2:STE 203
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4210
Practice Address - Country:US
Practice Address - Phone:770-733-7560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001018213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA131408692AMedicaid
GA5647140001Medicare NSC
GA131408692AMedicaid
GAGRP7182Medicare PIN