Basic Information
| Provider Information | |||||||||
| NPI: | 1417027277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300310910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042948180 | ||||||||
| FaxNumber: | 4042948188 | ||||||||
| Practice Location | |||||||||
| Address1: | 3292 MOUNTAIN DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300321102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042948180 | ||||||||
| FaxNumber: | 4042948188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 01/31/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 041305 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | BH1529897 | 01 | DEA | OTHER | 00715371B | 05 | GA | MEDICAID | 041305 | 01 | GA | STATE LICENSE | OTHER |