Healthcare Provider Details

I. General information

NPI: 1104895028
Provider Name (Legal Business Name): ROBERT ALLEN SHEELY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N SHORE PKWY STE A
BRANDON MS
39047-6383
US

IV. Provider business mailing address

1220 N SHORE PKWY STE A
BRANDON MS
39047-6383
US

V. Phone/Fax

Practice location:
  • Phone: 601-829-2939
  • Fax: 601-829-2995
Mailing address:
  • Phone: 601-829-2939
  • Fax: 601-829-2995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17053
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: