Provider Demographics
NPI:1093052656
Name:WILLIAM SHANAHAN
Entity Type:Organization
Organization Name:WILLIAM SHANAHAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-484-8448
Mailing Address - Street 1:4531 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2770
Mailing Address - Country:US
Mailing Address - Phone:850-484-8448
Mailing Address - Fax:850-479-3258
Practice Address - Street 1:4531 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2770
Practice Address - Country:US
Practice Address - Phone:850-484-8448
Practice Address - Fax:850-479-3258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0032249174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061290100Medicaid
FL061290100Medicaid