Healthcare Provider Details

I. General information

NPI: 1487627956
Provider Name (Legal Business Name): GREG R. SHIVER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 48 S
CAMILLA GA
31730
US

IV. Provider business mailing address

PO BOX 2548
ALBANY GA
31702-2548
US

V. Phone/Fax

Practice location:
  • Phone: 229-883-4297
  • Fax: 229-336-8200
Mailing address:
  • Phone: 229-312-5800
  • Fax: 229-312-5853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003049
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: