Provider Demographics
NPI:1306847785
Name:ROBERTS, RODNEY SHANE (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:SHANE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R SHANE
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:M D
Mailing Address - Street 1:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TN
Mailing Address - Zip Code:37322-0709
Mailing Address - Country:US
Mailing Address - Phone:423-334-2222
Mailing Address - Fax:423-334-2255
Practice Address - Street 1:398 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TN
Practice Address - Zip Code:37322-7759
Practice Address - Country:US
Practice Address - Phone:423-334-2222
Practice Address - Fax:423-334-2255
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN024022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN443935OtherRIVERBEND - RURAL HEALTH
TN0443935OtherMEDICAID
TN03718733Medicaid
TN621607679OtherEIN
TN443935OtherRIVERBEND - RURAL HEALTH
TNF45824Medicare UPIN