Healthcare Provider Details

I. General information

NPI: 1841485018
Provider Name (Legal Business Name): CRYSTAL SHANELLE DYER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL SHANELLE CARAWAY

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W MAIN ST STE 2
ROGERSVILLE TN
37857-3663
US

IV. Provider business mailing address

850 W MAIN ST STE 2
ROGERSVILLE TN
37857-3663
US

V. Phone/Fax

Practice location:
  • Phone: 423-500-0266
  • Fax: 423-500-4280
Mailing address:
  • Phone: 423-500-0266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101247662
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number44247
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: