Healthcare Provider Details

I. General information

NPI: 1891796595
Provider Name (Legal Business Name): SHANE C MANGRUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 02/12/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 HAMMOND DR SUITE 400
ATLANTA GA
30328-5334
US

IV. Provider business mailing address

1150 HAMMOND DR SUITE 400
ATLANTA GA
30328-5334
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-2633
  • Fax: 404-255-6532
Mailing address:
  • Phone: 404-256-2633
  • Fax: 404-255-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number73026
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberM9189
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: