Provider Demographics
NPI:1891839775
Name:SHATILLA, MAGGIE A (MD)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:A
Last Name:SHATILLA
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 1:509 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-1330
Mailing Address - Country:US
Mailing Address - Phone:803-245-6706
Mailing Address - Fax:803-245-6731
Practice Address - Street 1:509 NORTH ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1330
Practice Address - Country:US
Practice Address - Phone:803-245-6706
Practice Address - Fax:803-245-6731
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC194783Medicaid
SC194783Medicaid