Healthcare Provider Details

I. General information

NPI: 1235458183
Provider Name (Legal Business Name): SHAWN PATRICK MOUNTAIN D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PHYSICIANS WAY SUITE 110
LEBANON TN
37090-8102
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 615-547-6700
  • Fax: 615-547-6707
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2908
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0102203670
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number58.003128
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2908
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: