Provider Demographics
NPI:1558386698
Name:SHAFER, KILEY PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:KILEY
Middle Name:PATRICK
Last Name:SHAFER
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 1:355 AUDUBON CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7783
Mailing Address - Country:US
Mailing Address - Phone:601-919-8036
Mailing Address - Fax:
Practice Address - Street 1:2124 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4040
Practice Address - Country:US
Practice Address - Phone:601-553-6000
Practice Address - Fax:601-553-6115
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19129207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937118Medicaid
AL731-04414OtherBLUE CROSS BLUE SHIELD
MS06954074Medicaid