Provider Demographics
NPI:1649345273
Name:EDWARDS, SHELISE (MD)
Entity type:Individual
Prefix:
First Name:SHELISE
Middle Name:
Last Name:EDWARDS
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 1:235 PEACHTREE ST NE
Mailing Address - Street 2:NORTH TOWER, SUITE 2100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-1401
Mailing Address - Country:US
Mailing Address - Phone:770-994-9326
Mailing Address - Fax:770-994-4747
Practice Address - Street 1:235 PEACHTREE ST NE
Practice Address - Street 2:NORTH TOWER, SUITE 2100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1401
Practice Address - Country:US
Practice Address - Phone:770-994-9326
Practice Address - Fax:770-994-4747
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56453207PE0004X
IL036-117579207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117579-1Medicaid
IL036117579Medicaid
IL036117579OtherBLUE SHIELD
IL036117579Medicaid
ILK40832Medicare PIN