Provider Demographics
NPI:1407841398
Name:HIREMAGALUR, SHOBHA R (MD)
Entity Type:Individual
Prefix:
First Name:SHOBHA
Middle Name:R
Last Name:HIREMAGALUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6008
Mailing Address - Country:US
Mailing Address - Phone:423-979-6000
Mailing Address - Fax:423-979-6011
Practice Address - Street 1:310 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6008
Practice Address - Country:US
Practice Address - Phone:423-979-6000
Practice Address - Fax:423-979-6011
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD24677207RC0000X
TN24677207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01368158OtherRAILROAD MEDICARE
TN3086995Medicaid
VA1407841398Medicaid
KY64001035Medicaid
KY64001035Medicaid
VA005859166Medicaid
TNF92115Medicare UPIN
NC890596QMedicaid
TN3086999Medicaid
KY64001035Medicaid
TN3086999Medicare PIN
TN3058973OtherBLUE CROSS BLUE SHIELD