Healthcare Provider Details

I. General information

NPI: 1073801965
Provider Name (Legal Business Name): RANDI SHAE CONNOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 CENTRAL AVE
CHATTANOOGA TN
37403
US

IV. Provider business mailing address

102 CENTRAL AVE
CHATTANOOGA TN
37403-1503
US

V. Phone/Fax

Practice location:
  • Phone: 423-266-3636
  • Fax: 423-266-3633
Mailing address:
  • Phone: 423-266-3636
  • Fax: 423-266-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number57517
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: