Provider Demographics
NPI:1366630220
Name:SHANAHAN PODIATRY PA
Entity Type:Organization
Organization Name:SHANAHAN PODIATRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR TECHNOLOGIES
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:JULIA
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-685-6226
Mailing Address - Street 1:3909 GALEN CT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6824
Mailing Address - Country:US
Mailing Address - Phone:813-634-0664
Mailing Address - Fax:813-634-0668
Practice Address - Street 1:3909 GALEN CT
Practice Address - Street 2:SUITE 103
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6824
Practice Address - Country:US
Practice Address - Phone:813-634-0664
Practice Address - Fax:813-634-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3134213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5756010001Medicare NSC
FLV00135Medicare UPIN
FLK9762Medicare PIN