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General NPI Number Information
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NPI Number | 1912957739
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Entity Type | Individual
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Provider Name | EDWIN HAYWOOD SHUCK III MD
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Gender | Male
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Dates
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Enumeration Date | 05/11/2006
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Last Update Date | 02/03/2010
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Provider Practice Location Address
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Address Line | 2341 MCCALLIE AVE PLAZA 3 SUITE 305
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City | CHATTANOOGA
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State | TN
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Zip | 37404-3239
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Country | US
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Telephone | 423-622-2721
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Fax |
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Provider Business Mailing Address
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Address Line | 274 FRONTIER BLUFF RD
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City | LOOKOUT MOUNTAIN
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State | GA
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Zip | 30750-4160
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Country | US
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Telephone | 706-820-0519
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Fax | 706-820-8228
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 11816
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License Number State | TN
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