Provider Demographics
NPI:1225111651
Name:FOURTNER, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FOURTNER
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 1:5762 E MAIN STREET RD STE B
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-9621
Mailing Address - Country:US
Mailing Address - Phone:585-201-7112
Mailing Address - Fax:585-201-7128
Practice Address - Street 1:5762 E MAIN STREET RD STE B
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-9621
Practice Address - Country:US
Practice Address - Phone:585-201-7112
Practice Address - Fax:585-201-7128
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1416902080P0205X
NY2364272080P0205X
NMMD2017-10442080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02657463Medicaid
00027224401OtherUNIVERA
1212950OtherIHA
000528154001OtherBC/BS
050805000017OtherFIDELIS
1019564320001OtherPA MEDICAID
I33500Medicare UPIN
NYRA7301Medicare PIN