Healthcare Provider Details

I. General information

NPI: 1376527531
Provider Name (Legal Business Name): PHILIP SHRAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 PHILIP BLVD
LAWRENCEVILLE GA
30045-8733
US

IV. Provider business mailing address

PO BOX 116470
ATLANTA GA
30368-0001
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-3000
  • Fax: 770-995-1427
Mailing address:
  • Phone: 770-682-2080
  • Fax: 678-579-9398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number046327
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number46327
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: