Provider Demographics
NPI:1912957739
Name:SHUCK, EDWIN HAYWOOD III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:HAYWOOD
Last Name:SHUCK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:274 FRONTIER BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:LOOKOUT MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30750-4160
Mailing Address - Country:US
Mailing Address - Phone:706-820-0519
Mailing Address - Fax:706-820-8228
Practice Address - Street 1:2341 MCCALLIE AVE
Practice Address - Street 2:PLAZA 3 SUITE 305
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3239
Practice Address - Country:US
Practice Address - Phone:423-622-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11816208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN020051840OtherRAILROAD MEDICARE
TN0053980OtherBLUECROSS
B59410Medicare UPIN
3178976Medicare ID - Type Unspecified