Provider Demographics
NPI:1902211881
Name:BEESAM SHASHANK, REDDY (MD)
Entity Type:Individual
Prefix:
First Name:REDDY
Middle Name:
Last Name:BEESAM SHASHANK
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 1:1120 15TH ST STE BI1056
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:314-977-4850
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST DEPT OF
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0801062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003206806AMedicaid
GA080106OtherMEDICAL LICENSE