Healthcare Provider Details

I. General information

NPI: 1922035864
Provider Name (Legal Business Name): LARRY L SHEARS II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 E 3RD ST SUITE C520
CHATTANOOGA TN
37403-2136
US

IV. Provider business mailing address

975 E 3RD ST ATTN: PROVIDER ENROLLMENT
CHATTANOOGA TN
37403-2147
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-5661
  • Fax: 423-778-5664
Mailing address:
  • Phone: 423-778-5661
  • Fax: 423-778-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number55005
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number55005
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: