Provider Demographics
NPI:1801845383
Name:SHUCK, DIANE ALLEN
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ALLEN
Last Name:SHUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:DIANE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5623 OOLTEWAH RINGGOLD RD
Mailing Address - Street 2:PO BOX 731
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-7806
Mailing Address - Country:US
Mailing Address - Phone:423-238-5668
Mailing Address - Fax:423-238-5170
Practice Address - Street 1:5623 OOLTEWAH RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-7806
Practice Address - Country:US
Practice Address - Phone:423-238-5668
Practice Address - Fax:423-238-5170
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14062207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0036498OtherBLUE CROSS BLUE SHIELD
TN3009848Medicaid
TN010010624OtherRAILROAD MEDICARE
TN3009848Medicaid
E51747Medicare UPIN