Provider Demographics
NPI:1285827923
Name:MALIK, SHAHRAM (MD)
Entity Type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:MALIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:127 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-2853
Practice Address - Country:US
Practice Address - Phone:276-546-1440
Practice Address - Fax:423-224-3258
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245409207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA019715W82Medicare PIN
VAV V5979AMedicare PIN
TN103I086278Medicare PIN
TN103I084811Medicare PIN