Provider Demographics
NPI:1780628735
Name:SHEPARD, MARYANN BOLAND (MD)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:BOLAND
Last Name:SHEPARD
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-2842
Mailing Address - Fax:
Practice Address - Street 1:890 S PLEASANTBURG DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2455
Practice Address - Country:US
Practice Address - Phone:864-271-1450
Practice Address - Fax:864-271-3914
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12325208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0225337OtherCIGNA ID
SC123253Medicaid
SC4197855OtherAETNA
SC571004971003OtherBCBS OF SC ID
SC123253Medicaid