Provider Demographics
NPI:1427107036
Name:SHIRLEY, SUSAN ELENA (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELENA
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W 8TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2723
Mailing Address - Country:US
Mailing Address - Phone:706-291-8702
Mailing Address - Fax:
Practice Address - Street 1:311 W 8TH ST NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2723
Practice Address - Country:US
Practice Address - Phone:706-291-8702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052830207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA598765966AMedicaid
AL009942541Medicaid
GA22BDDZFMedicare PIN
GA598765966AMedicaid