Provider Demographics
NPI:1881693380
Name:SHUMAN, IVY LEE JR (MD)
Entity type:Individual
Prefix:DR
First Name:IVY
Middle Name:LEE
Last Name:SHUMAN
Suffix:JR
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 1:905 MONARCH CIR
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9197
Mailing Address - Country:US
Mailing Address - Phone:912-489-1153
Mailing Address - Fax:706-868-7809
Practice Address - Street 1:3694 BAY HILL CT
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-8994
Practice Address - Country:US
Practice Address - Phone:706-868-5232
Practice Address - Fax:706-868-7809
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017110207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADO5636Medicare UPIN