Provider Demographics
NPI:1003862400
Name:GALVIN, SHANNON R (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:GALVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST STE 5-704
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:312-695-0061
Mailing Address - Fax:312-695-9013
Practice Address - Street 1:251 E HURON ST STE 5-704
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-695-0061
Practice Address - Fax:312-695-9013
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020747367500000X
IL036121851207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2021655AMedicare ID - Type Unspecified
H38044Medicare UPIN