Healthcare Provider Details

I. General information

NPI: 1891193082
Provider Name (Legal Business Name): CONNIE HALL SHRAKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2014
Last Update Date: 06/21/2025
Certification Date: 06/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-3294
  • Fax: 678-312-3282
Mailing address:
  • Phone: 678-312-3294
  • Fax: 678-312-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number46326
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number46326
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number46326
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: