Provider Demographics
NPI:1831176460
Name:MARSHALL, SHIRLEY A (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:A
Last Name:MARSHALL
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 1:908 BRANTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-2531
Mailing Address - Country:US
Mailing Address - Phone:314-600-1368
Mailing Address - Fax:
Practice Address - Street 1:908 BRANTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2531
Practice Address - Country:US
Practice Address - Phone:314-600-1368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019590207Q00000X
MS21332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09981012Medicaid
MO207177916Medicaid
MO207177908Medicaid
MS9421650OtherAETNA
MSP00974926OtherRAILROAD MEDICARE
MS9421650OtherAETNA
MO207177916Medicaid