Healthcare Provider Details

I. General information

NPI: 1912957739
Provider Name (Legal Business Name): EDWIN HAYWOOD SHUCK III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/03/2010
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

274 FRONTIER BLUFF RD
LOOKOUT MOUNTAIN GA
30750-4160
US

V. Phone/Fax

Practice location:
  • Phone: 423-622-2721
  • Fax:
Mailing address:
  • Phone: 706-820-0519
  • Fax: 706-820-8228

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:
Title or Position:
Credential:
Phone: