=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376574905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES BRINSON SHIVER III M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 07/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2803 N COLUMBIA ST UNIT D
-----------------------------------------------------
City | MILLEDGEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31061-6448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-453-0662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2803 N COLUMBIA ST UNIT D
-----------------------------------------------------
City | MILLEDGEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31061-6448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-453-0662
-----------------------------------------------------
Fax | 478-452-8067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 044333
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------