Provider Demographics
NPI:1407897614
Name:MEREDITH, SHANNON MARIE (DPM)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3776
Mailing Address - Country:US
Mailing Address - Phone:207-879-3000
Mailing Address - Fax:
Practice Address - Street 1:195 FORE RIVER PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2780
Practice Address - Country:US
Practice Address - Phone:207-553-6682
Practice Address - Fax:207-553-6681
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME014284OtherANTHEM BLUE CROSS
ME104104OtherAETNA
ME480016606OtherRAILROAD MEDICARE
ME127440000Medicaid
14284OtherFEDERAL BLUE SHIELD
MEU47765OtherHARVARD PILGRIM
ME001299OtherMARTINS POINT
100429800OtherDEPT OF LABOR
MEMM555201Medicare PIN
MEMM5552Medicare PIN
MEU47765OtherHARVARD PILGRIM
U47765Medicare UPIN