Provider Demographics
NPI:1043257090
Name:SQUIRES, SHAYNE R (MD)
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:R
Last Name:SQUIRES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 PACES FERRY RD SE STE 1-1100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2151 W SPRING ST STE B110
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3209
Practice Address - Country:US
Practice Address - Phone:770-267-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62453207RC0000X
IA34402207U00000X
MA223248207U00000X
GA77557207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1043257090Medicaid
IAP00171707Medicare PIN
IA719260081Medicare PIN
IAI12387Medicare PIN