Provider Demographics
NPI:1578753521
Name:EDWARDS, DEVIN SHANE (MD)
Entity Type:Individual
Prefix:MR
First Name:DEVIN
Middle Name:SHANE
Last Name:EDWARDS
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:DEPT 888208
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-3367
Mailing Address - Country:US
Mailing Address - Phone:423-587-8041
Mailing Address - Fax:423-587-8035
Practice Address - Street 1:1437 W MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-2828
Practice Address - Country:US
Practice Address - Phone:423-587-8041
Practice Address - Fax:423-587-8035
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116016609208600000X
TNMD45382208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515417Medicaid
TN1515417Medicaid
TN103I022946Medicare PIN