Provider Demographics
NPI:1083882336
Name:COLON & RECTAL SURGERY ASSOCIATES PA
Entity Type:Organization
Organization Name:COLON & RECTAL SURGERY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:HAYWOOD
Authorized Official - Last Name:SHUCK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:423-622-2721
Mailing Address - Street 1:2341 MCCALLIE AVE
Mailing Address - Street 2:PLAZA 3 SUITE 305
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3239
Mailing Address - Country:US
Mailing Address - Phone:426-622-2721
Mailing Address - Fax:423-622-5368
Practice Address - Street 1:2341 MCCALLIE AVE
Practice Address - Street 2:PLAZA 3 SUITE 305
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3239
Practice Address - Country:US
Practice Address - Phone:426-622-2721
Practice Address - Fax:423-622-5368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11816208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CJ8120OtherRAILROAD MEDICARE GROUP
CJ8120OtherRAILROAD MEDICARE GROUP