1063405736 NPI number — ROGER J MCSHARRY MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063405736 NPI number — ROGER J MCSHARRY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCSHARRY
Provider First Name:
ROGER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063405736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 W STONE DR
Provider Second Line Business Mailing Address:
SUITE 6A
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-3365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-408-7220
Provider Business Mailing Address Fax Number:
423-408-7405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
271 MEDICAL PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-7455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-968-2311
Provider Business Practice Location Address Fax Number:
423-968-2311
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  MD0000028511 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 0101054883 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 290008725 . This is a "PALMETTO RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3804276 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 290000173 . This is a "TRAILBLAZERS MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 290008725 . This is a "PALMETTO RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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