Provider Demographics
NPI:1629094388
Name:MEADE, SHANNON L (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:MEADE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19229 MACK AVE
Mailing Address - Street 2:STE 10
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:313-647-3100
Mailing Address - Fax:313-647-3111
Practice Address - Street 1:19229 MACK AVE
Practice Address - Street 2:STE 10
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-647-3100
Practice Address - Fax:313-647-3111
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0044882085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM90750009Medicare ID - Type Unspecified
Q48060Medicare UPIN