Provider Demographics
NPI:1003110743
Name:GLOVER, SHELLE RAE (MD)
Entity Type:Individual
Prefix:
First Name:SHELLE
Middle Name:RAE
Last Name:GLOVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:304 SHORTER AVE NW STE 201
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4256
Practice Address - Country:US
Practice Address - Phone:706-509-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA073349207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003158366AMedicaid
GA003158366AMedicaid