Healthcare Provider Details

I. General information

NPI: 1831177179
Provider Name (Legal Business Name): SHANE KUDELA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 BAXTER ST
ATHENS GA
30606
US

IV. Provider business mailing address

485 HUNTINGTON RD #180
ATHENS GA
30606
US

V. Phone/Fax

Practice location:
  • Phone: 706-548-7581
  • Fax:
Mailing address:
  • Phone: 706-546-6841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number40712
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: