Healthcare Provider Details

I. General information

NPI: 1083882336
Provider Name (Legal Business Name): COLON & RECTAL SURGERY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2341 MCCALLIE AVE PLAZA 3 SUITE 305
CHATTANOOGA TN
37404-3239
US

IV. Provider business mailing address

2341 MCCALLIE AVE PLAZA 3 SUITE 305
CHATTANOOGA TN
37404-3239
US

V. Phone/Fax

Practice location:
  • Phone: 426-622-2721
  • Fax: 423-622-5368
Mailing address:
  • Phone: 426-622-2721
  • Fax: 423-622-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number11816
License Number StateTN

VIII. Authorized Official

Name: DR. EDWIN HAYWOOD SHUCK III
Title or Position: PRESIDENT
Credential: MD
Phone: 423-622-2721