Provider Demographics
NPI:1457306821
Name:SHAVER, ELLEN G (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:G
Last Name:SHAVER
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:PO BOX 204630
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30917-4630
Mailing Address - Country:US
Mailing Address - Phone:706-722-6957
Mailing Address - Fax:706-722-7454
Practice Address - Street 1:840 STEVENS CREEK RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907
Practice Address - Country:US
Practice Address - Phone:706-722-6957
Practice Address - Fax:706-722-7454
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041670207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG41670Medicaid
GA000709607EMedicaid
GA000709607GMedicaid
SCG41670Medicaid
GA000709607EMedicaid