Provider Demographics
NPI:1891796595
Name:MANGRUM, SHANE C (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:C
Last Name:MANGRUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1150 HAMMOND DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5334
Mailing Address - Country:US
Mailing Address - Phone:404-256-2633
Mailing Address - Fax:404-255-6532
Practice Address - Street 1:1150 HAMMOND DR
Practice Address - Street 2:SUITE 400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5334
Practice Address - Country:US
Practice Address - Phone:404-256-2633
Practice Address - Fax:404-255-6532
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2015-04-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM9189225400000X
GA730262081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807178100Medicaid
IDI26566Medicare UPIN
IDI26566Medicare UPIN