Provider Demographics
NPI:1174664163
Name:SMITH, SHANON DAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANON
Middle Name:DAIL
Last Name:SMITH
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 1:715 N SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-4451
Mailing Address - Country:US
Mailing Address - Phone:402-463-0404
Mailing Address - Fax:402-462-4264
Practice Address - Street 1:715 N SAINT JOSEPH AVE
Practice Address - Street 2:HASTINGS RADIOLOGY ASSOCIATES
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-4451
Practice Address - Country:US
Practice Address - Phone:402-461-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22687207R00000X
GA0545132085R0202X
NE251672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine