1811968589 NPI number — TIMOTHY J SHANNON MD

Table of content: TIMOTHY J SHANNON MD (NPI 1811968589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811968589 NPI number — TIMOTHY J SHANNON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
TIMOTHY
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:
1811968589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 UNIVERSITY PKWY
Provider Second Line Business Mailing Address:
SUITE 1000
Provider Business Mailing Address City Name:
AIKEN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-644-4264
Provider Business Mailing Address Fax Number:
803-649-0543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
SUITE 1000
Provider Business Practice Location Address City Name:
AIKEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-644-4264
Provider Business Practice Location Address Fax Number:
803-649-0543
Provider Enumeration Date:
01/30/2006

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: 207X00000X , with the licence number:  17950 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: T18656 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com