Provider Demographics
NPI:1609072842
Name:SHIRES, COURTNEY BROOKE (MD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BROOKE
Last Name:SHIRES
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 1:7714 POPLAR AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3941
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-685-2969
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:901-685-2969
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29339207Y00000X
TN48308207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193392001Medicaid
MS04088114Medicaid
TN1529232Medicaid
TNQ002445Medicaid