Provider Demographics
NPI:1568633964
Name:SHANNON FAMILY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:SHANNON FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NORRIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:DOSS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-995-2201
Mailing Address - Street 1:219 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SHANNON
Mailing Address - State:MS
Mailing Address - Zip Code:38868-9301
Mailing Address - Country:US
Mailing Address - Phone:662-995-2201
Mailing Address - Fax:662-995-2202
Practice Address - Street 1:219 BROAD ST
Practice Address - Street 2:
Practice Address - City:SHANNON
Practice Address - State:MS
Practice Address - Zip Code:38868
Practice Address - Country:US
Practice Address - Phone:662-995-2201
Practice Address - Fax:662-995-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR819576261QR1300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05188209Medicaid
MS258906Medicare Oscar/Certification
MS05188209Medicaid