Provider Demographics
NPI:1174967723
Name:SHASTEEN, MALLORY ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:SHASTEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MALLORY
Other - Middle Name:ELIZABETH
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 E MCBEE AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2899
Mailing Address - Country:US
Mailing Address - Phone:864-522-2286
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC398262080S0010X, 207QS0010X, 207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program