Provider Demographics
NPI:1770547994
Name:REINES, SUSAN SHAW (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:SHAW
Last Name:REINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-364-7000
Mailing Address - Fax:
Practice Address - Street 1:8011 MALL PARKWAY
Practice Address - Street 2:KAISER PERMANENTE STONECREST MEDICAL CENTER
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038
Practice Address - Country:US
Practice Address - Phone:678-323-7510
Practice Address - Fax:678-323-7522
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032809208000000X
GA32809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF16014Medicare UPIN