Provider Demographics
NPI:1104845734
Name:SHANNON, JOHN JAY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JAY
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 1:1900 W POLK ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-864-5504
Mailing Address - Fax:312-864-9994
Practice Address - Street 1:1900 W POLK ST
Practice Address - Street 2:SUITE 220
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-5504
Practice Address - Fax:312-864-9994
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079704207R00000X, 207RC0200X, 207RP1001X
TXH2772207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE05107Medicare UPIN