Provider Demographics
NPI:1417916859
Name:SHANIK, EDWARD JOEL (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOEL
Last Name:SHANIK
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 1:260 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2467
Mailing Address - Country:US
Mailing Address - Phone:770-887-1668
Mailing Address - Fax:770-781-9937
Practice Address - Street 1:260 ELM ST
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2467
Practice Address - Country:US
Practice Address - Phone:770-887-1668
Practice Address - Fax:770-781-9937
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000193179KMedicaid
TN4048222Medicaid
GA00193179JMedicaid
GA01160889OtherAMERIGROUP
GA52023332OtherBCBS GA
GA000193179LMedicaid
GA000193179MMedicaid
TN4186949OtherBCBS TN
GA000193179KMedicaid
TN4186949OtherBCBS TN
GA000193179MMedicaid
GA01160889OtherAMERIGROUP
GA511I080169Medicare PIN