Basic Information
| Provider Information | |||||||||
| NPI: | 1770547994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REINES | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | SHAW | ||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | SHAW | ||||||||
| OtherFirstName: | SUSAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8011 MALL PARKWAY | ||||||||
| Address2: | KAISER PERMANENTE STONECREST MEDICAL CENTER | ||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783237510 | ||||||||
| FaxNumber: | 6783237522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 032809 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 174400000X | 32809 | GA | N | Other Service Providers | Specialist |
No ID Information.