Provider Demographics
NPI:1578538765
Name:SHANNON, KELLY T (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:T
Last Name:SHANNON
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 1:300 HALKET ST
Mailing Address - Street 2:MAGEE-WOMENS HOSPITAL
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-3108
Mailing Address - Country:US
Mailing Address - Phone:412-641-4260
Mailing Address - Fax:
Practice Address - Street 1:300 HALKET ST
Practice Address - Street 2:MAGEE-WOMENS HOSPITAL
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3108
Practice Address - Country:US
Practice Address - Phone:412-641-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046472L174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA719300FEVMedicare PIN
PAF26931Medicare UPIN