Basic Information
| Provider Information | |||||||||
| NPI: | 1336139914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 590472624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4069952792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 MULKEY RD | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301061186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709413633 | ||||||||
| FaxNumber: | 7709449038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 01/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 352 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000006113B | 05 | GA | MEDICAID | 1756369 | 05 | LA | MEDICAID |