Basic Information
| Provider Information | |||||||||
| NPI: | 1538143383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 25TH AVE N STE 1204 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153120600 | ||||||||
| FaxNumber: | 6153203259 | ||||||||
| Practice Location | |||||||||
| Address1: | 3310 ASPEN GROVE DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157718274 | ||||||||
| FaxNumber: | 6157718674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 30364 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 30364 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | Q035443 | 05 | TN | MEDICAID |