Provider Demographics
NPI:1376527531
Name:SHRAKE, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:SHRAKE
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:PO BOX 116470
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-0001
Mailing Address - Country:US
Mailing Address - Phone:770-682-2080
Mailing Address - Fax:678-579-9398
Practice Address - Street 1:311 PHILIP BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8733
Practice Address - Country:US
Practice Address - Phone:770-995-3000
Practice Address - Fax:770-995-1427
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046327174400000X
GA463272085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000809729DMedicaid
GA00809729AMedicaid
GA92BBGCSMedicare PIN
GA92BDDJBMedicare ID - Type Unspecified
GA00809729AMedicaid