Basic Information
| Provider Information | |||||||||
| NPI: | 1558386698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAFER | ||||||||
| FirstName: | KILEY | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 AUDUBON CIR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390477783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019198036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2124 14TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015536000 | ||||||||
| FaxNumber: | 6015536115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 19129 | MS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009937118 | 05 | AL | MEDICAID | 731-04414 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 06954074 | 05 | MS | MEDICAID |