Provider Demographics
NPI:1942313572
Name:SHACK, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:SHACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3400 C OLD MILTON PARKWAY
Mailing Address - Street 2:SUITE 270
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:770-442-1911
Mailing Address - Fax:770-663-8905
Practice Address - Street 1:3400 C OLD MILTON PARKWAY
Practice Address - Street 2:SUITE 270
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005
Practice Address - Country:US
Practice Address - Phone:770-442-1911
Practice Address - Fax:770-663-8905
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2015-06-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL22858207Q00000X
GA061856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009960760Medicaid
AL051502030OtherBCBS
AL051502030Medicare ID - Type UnspecifiedMEDICARE
ALH17755Medicare UPIN