Provider Demographics
NPI:1962466276
Name:SHALLCROSS, DAVID LEE (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:SHALLCROSS
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:STE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:111 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5608
Practice Address - Country:US
Practice Address - Phone:864-797-7100
Practice Address - Fax:864-797-7105
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15001208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAPPROVEDMedicaid
SCAPPROVEDMedicare PIN
SCE563383640Medicare PIN
SCP00778941OtherRR MEDICARE
SCE563385235Medicare PIN
SCE56338Medicare UPIN
SC140010Medicaid