Provider Demographics
NPI:1114996964
Name:SHIVER, MARILYN RAYBURN (PT, MS)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:RAYBURN
Last Name:SHIVER
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:MISS
Other - First Name:MARILYN
Other - Middle Name:ELIZABETH
Other - Last Name:RAYBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MS
Mailing Address - Street 1:4555 NORTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-6749
Mailing Address - Country:US
Mailing Address - Phone:229-336-0105
Mailing Address - Fax:
Practice Address - Street 1:99 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1807
Practice Address - Country:US
Practice Address - Phone:229-336-1115
Practice Address - Fax:229-336-1151
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007735225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA829428929AMedicaid
P00247221OtherPALMETTO GBA - RR MEDICAR
GA829428929AMedicaid
P00247221OtherPALMETTO GBA - RR MEDICAR