Active NPI
R. Shane Roberts, M.D., Inc.
- Family Medicine Physician
- Decatur, TN
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 024022
- Legal business name
- R. SHANE ROBERTS, M.D., INC.
- Practice address
- 398 N Main St
Decatur, TN 37322-7759 - Phone
- (423) 334-2222
- Fax
- (423) 334-2255
- NPI assigned
- Jun 22, 2007
- Last updated
- Mar 10, 2022
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- R. Shane Roberts, M.D.
- Title
- Owner
- Phone
- (423) 334-2222
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 024022 | TN | Primary |
Addresses
Primary practice location
398 N Main St
Decatur, TN 37322-7759
Mailing address
398 N Main St
Decatur, TN 37322-7759
Phone (423) 334-2222
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3718733 | Medicaid | TN | |
| 0443935 | Medicaid | TN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TN
Enrollment records 2
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1508062977. Details of each certification follow.
Rural health clinic certification: CCN 443935
- Legal name
- R. SHANE ROBERTS, M.D., INC.
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Sep 15, 2003
- Last certification
- May 2, 2018
- Ownership / control type
- 1B
- Organization structure
- Corporation
- Incorporated
- Jun 29, 1995 in TN
- Enrollment address
- 398 North Main Street
Decatur, TN 37322-7759
Other NPIs with the same Medicare PAC ID 1
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
Other NPIs on the same Medicare enrollment 1
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
National Provider Directory
National Provider DirectoryLocations
398 N Main St
Decatur, TN 37322
Phone (423) 334-2222
Ownership & related parties
All disclosed owners & managing parties 3
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Rodney Roberts | 5% Or Greater Direct Ownership Interest | Jun 12, 1995 | 51% |
| W-2 Managing Employee | Jun 12, 1995 | ||
| Sharon Roberts | 5% Or Greater Direct Ownership Interest | Jun 12, 1995 | 49% |
| Corporate Officer | Jun 12, 1995 | ||
| Debbie D Walden | Contracted Managing Employee | Nov 1, 2025 | |
| W-2 Managing Employee | Nov 1, 2025 | ||
| Operational/Managerial Control | Nov 1, 2025 |
Owners & managing parties with NPI records 1
Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.
-
- Family Medicine Physician
- Decatur, TN
- NPI 1306847785
5% Or Greater Direct Ownership Interest, W-2 Managing Employee
Subparts reporting this organization as parent 1
Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.
-
- Family Medicine Physician
- Decatur, TN
- NPI 1740936178
Practitioners & affiliated clinicians
Practitioners 2
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.
-
- Family Nurse Practitioner
- Talbott, TN
- NPI 1396756342
-
- Family Medicine Physician
- Decatur, TN
- NPI 1306847785
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1182470400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1646870400000",
"number": "1508062977",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "398 N MAIN ST",
"city": "DECATUR",
"state": "TN",
"postal_code": "373227759",
"telephone_number": "423-334-2222",
"fax_number": "423-334-2255"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "398 N MAIN ST",
"city": "DECATUR",
"state": "TN",
"postal_code": "373227759",
"telephone_number": "423-334-2222",
"fax_number": "423-334-2255"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "R. SHANE ROBERTS, M.D., INC.",
"organizational_subpart": "NO",
"enumeration_date": "2007-06-22",
"last_updated": "2022-03-10",
"certification_date": "2022-03-10",
"status": "A",
"authorized_official_last_name": "ROBERTS",
"authorized_official_first_name": "R. SHANE",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "423-334-2222",
"authorized_official_credential": "M.D."
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "TN",
"license": "024022",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "3718733",
"state": "TN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0443935",
"state": "TN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Decatur, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.