Provider Demographics
NPI:1396057139
Name:CONERLY-SHAM, SARAH ELIZABETH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:CONERLY-SHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:CONERLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:UNIVERSITY OF MS MEDICAL CENTER
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4505
Mailing Address - Country:US
Mailing Address - Phone:601-984-5210
Mailing Address - Fax:601-815-4942
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:UNIVERSITY OF MS MEDICAL CENTER
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5210
Practice Address - Fax:601-984-2086
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2298208000000X
MS22487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00577519Medicaid
MS00577519Medicaid