Provider Demographics
NPI:1720044456
Name:SHIRLEY, STEPHEN MILAN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MILAN
Last Name:SHIRLEY
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 1:400 DOCTORS DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652
Mailing Address - Country:US
Mailing Address - Phone:662-534-5036
Mailing Address - Fax:662-534-9696
Practice Address - Street 1:400 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3109
Practice Address - Country:US
Practice Address - Phone:662-534-5036
Practice Address - Fax:662-534-9696
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018005Medicaid
MS080001379Medicare ID - Type Unspecified
MSB31045Medicare UPIN