Provider Demographics
NPI:1235145152
Name:SHULL, ROBERT T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:T
Last Name:SHULL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:640 HEADDEN DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELY
Mailing Address - State:TN
Mailing Address - Zip Code:38080-1215
Mailing Address - Country:US
Mailing Address - Phone:731-264-5688
Mailing Address - Fax:
Practice Address - Street 1:200 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4223
Practice Address - Country:US
Practice Address - Phone:870-735-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-4402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D70204Medicare UPIN