Healthcare Provider Details

I. General information

NPI: 1841277308
Provider Name (Legal Business Name): MOHAMED BASHAR ABOU SHALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MOHAMED BASHAR ABOU SHALA MD

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6799 GREAT OAKS RD
MEMPHIS TN
38138-2588
US

IV. Provider business mailing address

6799 GREAT OAKS RD
MEMPHIS TN
38138-2588
US

V. Phone/Fax

Practice location:
  • Phone: 901-751-0405
  • Fax: 901-751-9694
Mailing address:
  • Phone: 901-751-0405
  • Fax: 901-751-9694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number26593
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number26593
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: