Provider Demographics
NPI:1356553408
Name:INNIS-SHELTON, RACQUEL D (MD)
Entity type:Individual
Prefix:
First Name:RACQUEL
Middle Name:D
Last Name:INNIS-SHELTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:205-297-9411
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-1900
Practice Address - Country:US
Practice Address - Phone:205-934-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116018506390200000X
AL28895390200000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04523704Medicaid
AL110873Medicaid
AL051598339OtherBLUE CROSS & BLUE SHIELD AL
AL051598340OtherBLUE CROSS & BLUE SHIELD AL
AL110794Medicaid
AL051598336OtherBLUE CROSS & BLUE SHIELD AL
AL110861Medicaid
AL110869Medicaid
AL051598338OtherBLUE CROSS & BLUE SHIELD AL
102I014862OtherMEDICARE