Provider Demographics
NPI:1760439392
Name:CHANDRAIAH, SHAMBHAVI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAMBHAVI
Middle Name:
Last Name:CHANDRAIAH
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-8000
Mailing Address - Fax:423-439-2200
Practice Address - Street 1:2 PROFESSIONAL PARK DR STE 21
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6584
Practice Address - Country:US
Practice Address - Phone:423-379-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN520602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122774Medicaid
TNQ008958Medicaid
MS260045972OtherPALMETTO GBA-RAILROAD MED
MSP00634032OtherRR MEDICARE
MSE89697Medicare UPIN
MS00122774Medicaid
MSP01077297Medicare PIN
MS260000495Medicare ID - Type Unspecified