MEDICARE: KELLY SHADMAN PHILLIPS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA0000001512	TN
2	363A00000X	Physician Assistant	0010-03244	NC
3	363AM0700X	Medical Physician Assistant	1512	TN
4	363A00000X	Physician Assistant	1512	TN
5	363A00000X	Physician Assistant	007088	GA
6	363A00000X	Physician Assistant	PA.0009629	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194915496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY SHADMAN PHILLIPS PA-C

Provider Business Mailing Address
First Line	:	3400 OLD MILTON PKWY # C
Second Line	:	SUITE 290
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-3707
Country	:	US
Telephone Number	:	770-667-4337
Fax Number	:	770-667-4338

Provider Business Practice Location Address
First Line	:	1505 NORTHSIDE FORSYTH BLVD
Second Line	:	STE 3500
City	:	CUMMING
State	:	GA
Zip	:	30041
Country	:	US
Telephone Number	:	770-292-6500
Fax Number	:	770-292-6535

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2007
Last Update Date	:	06/10/2026

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