Provider Demographics
NPI:1164531497
Name:SHANNON, MICHAEL CAROLL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CAROLL
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1101 MADISON ST STE 800
Mailing Address - Street 2:SWEDISH PEDIATRIC SPECIALTY CARE
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1307
Mailing Address - Country:US
Mailing Address - Phone:206-215-2700
Mailing Address - Fax:206-215-2702
Practice Address - Street 1:1101 MADISON ST STE 800
Practice Address - Street 2:SWEDISH PEDIATRIC SPECIALTY CARE
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1307
Practice Address - Country:US
Practice Address - Phone:206-215-2700
Practice Address - Fax:206-215-2702
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD600964712080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8549958Medicaid
NML6647Medicaid
NMNM301284Medicare PIN
P002101056Medicare ID - Type Unspecified
WA8549958Medicaid
E16328Medicare UPIN
NM348424102Medicare PIN