Basic Information
| Provider Information | |||||||||
| NPI: | 1356553408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INNIS-SHELTON | ||||||||
| FirstName: | RACQUEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55310 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352555310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057319701 | ||||||||
| FaxNumber: | 2052979411 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 19TH ST S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352491900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059344011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 04/19/2011 | ||||||||
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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 | 390200000X | 0116018506 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | 28895 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 051598338 | 01 | AL | BLUE CROSS & BLUE SHIELD AL | OTHER | 110794 | 05 | AL | MEDICAID | 110869 | 05 | AL | MEDICAID | 051598339 | 01 | AL | BLUE CROSS & BLUE SHIELD AL | OTHER | 110873 | 05 | AL | MEDICAID | 04523704 | 05 | MS | MEDICAID | 051598340 | 01 | AL | BLUE CROSS & BLUE SHIELD AL | OTHER | 110861 | 05 | AL | MEDICAID | 051598336 | 01 | AL | BLUE CROSS & BLUE SHIELD AL | OTHER | 102I014862 | 01 | MEDICARE | OTHER |