Provider Demographics
NPI:1063463743
Name:SHALLEY, ANN MARGARET (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARGARET
Last Name:SHALLEY
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:390 KEOWEE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-6743
Practice Address - Country:US
Practice Address - Phone:864-885-7129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27335207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863095OtherBCBS OF SC ID
SC273359Medicaid
SCP00160236OtherRR MEDICARE
SC2144092OtherCIGNA ID
SC576007863057OtherBLUECHOICE HEALTHPLAN ID
SC4123835OtherAETNA ID
SCC324873640Medicare PIN
SC576007863095OtherBCBS OF SC ID
SC576007863057OtherBLUECHOICE HEALTHPLAN ID