Healthcare Provider Details

I. General information

NPI: 1134745953
Provider Name (Legal Business Name): MOLLY C SHIELDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DUGAS BUILDING BG 107 1120 15TH STREET
AUGUSTA GA
30912-0001
US

IV. Provider business mailing address

680 CRANE CREEK DR APT 611
AUGUSTA GA
30907-3094
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11930
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: