Healthcare Provider Details

I. General information

NPI: 1306847785
Provider Name (Legal Business Name): RODNEY SHANE ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: R SHANE ROBERTS M D

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 N MAIN ST
DECATUR TN
37322-7759
US

IV. Provider business mailing address

PO BOX 709
DECATUR TN
37322-0709
US

V. Phone/Fax

Practice location:
  • Phone: 423-334-2222
  • Fax: 423-334-2255
Mailing address:
  • Phone: 423-334-2222
  • Fax: 423-334-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number024022
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: