MEDICARE: DR. IVY LEE SHUMAN JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	017110	GA

General Provider Information

NPI Number	:	1881693380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVY LEE SHUMAN JR. M.D.

Provider Business Mailing Address
First Line	:	905 MONARCH CIR
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-9197
Country	:	US
Telephone Number	:	912-489-1153
Fax Number	:	706-868-7809

Provider Business Practice Location Address
First Line	:	3694 BAY HILL CT
Second Line	:
City	:	MARTINEZ
State	:	GA
Zip	:	30907-8994
Country	:	US
Telephone Number	:	706-868-5232
Fax Number	:	706-868-7809

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	07/09/2007

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