=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104895028
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT ALLEN SHEELY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 N SHORE PKWY STE A
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39047-6383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-829-2939
-----------------------------------------------------
Fax | 601-829-2995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 N SHORE PKWY STE A
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39047-6383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-829-2939
-----------------------------------------------------
Fax | 601-829-2995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 17053
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------