Basic Information
| Provider Information | |||||||||
| NPI: | 1023466570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHILLINGER | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIMSEY | ||||||||
| OtherFirstName: | MALLORY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 117264 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063695440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 HAWTHORNE PARK | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063538700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 208D00000X | FL | N | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | 84754 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.