Provider Demographics
NPI:1699786079
Name:MULL, SHANE R (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:R
Last Name:MULL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 WESTLAKE FARMS DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-8325
Mailing Address - Country:US
Mailing Address - Phone:803-917-9333
Mailing Address - Fax:
Practice Address - Street 1:3209 COLONIAL DR
Practice Address - Street 2:USC- FAMILY & PREVENTIVE MEDICINE
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6930
Practice Address - Country:US
Practice Address - Phone:803-434-6113
Practice Address - Fax:803-434-7231
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23962207P00000X, 207Q00000X
NC2009-01329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLL4378Medicaid
SCAA05692461Medicare PIN
SCAA05696126Medicare PIN
SCAA05694713Medicare PIN
SCAA05962353Medicare PIN
SCAA05696125Medicare PIN
SCAA05697136Medicare PIN
SCAA05696201Medicare PIN