Provider Demographics
NPI:1912901513
Name:SHUMAKER, GRACE G (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:G
Last Name:SHUMAKER
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 1:1227 N STATE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2002
Mailing Address - Country:US
Mailing Address - Phone:601-355-2485
Mailing Address - Fax:601-353-1463
Practice Address - Street 1:1227 N STATE ST
Practice Address - Street 2:STE 101
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2002
Practice Address - Country:US
Practice Address - Phone:601-355-2485
Practice Address - Fax:601-353-1463
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11423207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116633Medicaid
4389669OtherAETNA HEALTHCARE
E46633Medicare UPIN
MS00116633Medicaid