Provider Demographics
NPI:1336134774
Name:HENNON, SHAUN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:
Last Name:HENNON
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 1:4135 BOARDMAN CANFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:740 E STATE ST
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:PA
Practice Address - Zip Code:16146-3328
Practice Address - Country:US
Practice Address - Phone:724-983-7310
Practice Address - Fax:724-983-2797
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.054938207L00000X
PAMD435728207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA138641ZB29OtherMEDICARE PTAN
PAHE98068OtherHIGHMARK BCBS
OH000000594276OtherANTHEM BCBS
PA0014592000005Medicaid
PAP00670883OtherMEDICARE RAILROAD
OH0744298Medicaid
10828939OtherCAQH
10828939OtherCAQH