Provider Demographics
NPI:1841277308
Name:SHALA, MOHAMED BASHAR ABOU (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED BASHAR
Middle Name:ABOU
Last Name:SHALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAMED BASHAR
Other - Middle Name:ABOU
Other - Last Name:SHALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6799 GREAT OAKS RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2588
Mailing Address - Country:US
Mailing Address - Phone:901-751-0405
Mailing Address - Fax:901-751-9694
Practice Address - Street 1:6799 GREAT OAKS RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38138-2588
Practice Address - Country:US
Practice Address - Phone:901-751-0405
Practice Address - Fax:901-751-9694
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26593207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4146206OtherBCBS
TNP00378331OtherRAIL ROAD MEDICARE
TN5188055OtherAETNA
MSP00393920OtherRAIL ROAD MEDICARE
TN3094124Medicaid
TN000000015934OtherTLC
MS00116832Medicaid
02100041401OtherQUALCHOICE
AR97426OtherBCBS
F92946Medicare UPIN
TN10306I6501Medicare PIN
02100041401OtherQUALCHOICE