Healthcare Provider Details

I. General information

NPI: 1508062977
Provider Name (Legal Business Name): R. SHANE ROBERTS, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 N MAIN ST
DECATUR TN
37322-7759
US

IV. Provider business mailing address

398 N MAIN ST
DECATUR TN
37322-7759
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: R. SHANE ROBERTS
Title or Position: OWNER
Credential: M.D.
Phone: 423-334-2222