Provider Demographics
NPI:1972565463
Name:SHULL, MICHAEL TODD (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:SHULL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 HONEYSUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6486
Mailing Address - Country:US
Mailing Address - Phone:912-576-8169
Mailing Address - Fax:
Practice Address - Street 1:881 USS JAMES MADISON RD
Practice Address - Street 2:
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547-2531
Practice Address - Country:US
Practice Address - Phone:912-573-2410
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman