Provider Demographics
NPI:1659337772
Name:SHINE, SUSANNE MAYER (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:MAYER
Last Name:SHINE
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 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:1901 S SHADY ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-2021
Practice Address - Country:US
Practice Address - Phone:423-727-1103
Practice Address - Fax:423-727-1140
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD28373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3803942Medicaid
VA1659337772Medicaid
TN4062633OtherBCBS
TN080137334OtherRAILROAD MEDICARE
TNQ009918Medicaid
TNTN0168OtherJOHN DEERE
TNQ009918Medicaid
TN3803942Medicare PIN