Provider Demographics
NPI:1073629028
Name:SHANNON, PAMELA D (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:SHANNON
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 1:315 WEST 10TH STREET
Mailing Address - Street 2:STE 110 AFFORDABLE HEALTH CARE LLC
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165
Mailing Address - Country:US
Mailing Address - Phone:706-802-1322
Mailing Address - Fax:706-802-0716
Practice Address - Street 1:315 WEST 10TH STREET
Practice Address - Street 2:STE 110 AFFORDABLE HEALTH CARE LLC
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165
Practice Address - Country:US
Practice Address - Phone:706-802-1322
Practice Address - Fax:706-802-0716
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00806715CMedicaid
G81334Medicare UPIN
11BDSLPMedicare PIN