Healthcare Provider Details

I. General information

NPI: 1912726332
Provider Name (Legal Business Name): KYLE SHUMEYKO PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 MACARTHUR BLVD NW
ATLANTA GA
30318-2023
US

IV. Provider business mailing address

1105 TOWN BLVD NE UNIT 2317
BROOKHAVEN GA
30319-3674
US

V. Phone/Fax

Practice location:
  • Phone: 770-268-5893
  • Fax:
Mailing address:
  • Phone: 678-357-5430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT015880
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: