Provider Demographics
NPI:1043210727
Name:SHANNON, MICHAEL B (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 BELL ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1741
Mailing Address - Country:US
Mailing Address - Phone:740-453-6543
Mailing Address - Fax:740-453-1168
Practice Address - Street 1:2809 BELL ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2861
Practice Address - Country:US
Practice Address - Phone:740-453-6543
Practice Address - Fax:740-453-1168
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-2695-5207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0619156Medicaid
OH31116457500OtherBWC
OH0619156Medicaid
OH31116457500OtherBWC