Provider Demographics
NPI:1124058276
Name:GARABEDIAN, SHANT HAGOP (DO)
Entity type:Individual
Prefix:
First Name:SHANT
Middle Name:HAGOP
Last Name:GARABEDIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BARRETT PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1918
Mailing Address - Country:US
Mailing Address - Phone:731-695-8215
Mailing Address - Fax:
Practice Address - Street 1:367 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2080
Practice Address - Country:US
Practice Address - Phone:731-661-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1274207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3830111Medicaid
P00268882OtherRR MEDICARE
4105328OtherBCBS
TN3830112Medicaid
TN3830111Medicaid
TN3830111Medicare PIN
TN3830112Medicaid