Provider Demographics
NPI:1487627956
Name:SHIVER, GREG R (PA)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:R
Last Name:SHIVER
Suffix:
Gender:M
Credentials:PA
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 2548
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-2548
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:229-312-5853
Practice Address - Street 1:US HWY 48 S
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730
Practice Address - Country:US
Practice Address - Phone:229-883-4297
Practice Address - Fax:229-336-8200
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97BBDFMMedicare ID - Type Unspecified
GAS53692Medicare UPIN