Provider Demographics
NPI:1669460101
Name:SHANNON, STEVEN (DPM)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 MARKET ST
Mailing Address - Street 2:MAB # 111
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3153
Mailing Address - Country:US
Mailing Address - Phone:215-662-9563
Mailing Address - Fax:215-243-8818
Practice Address - Street 1:3801 MARKET ST
Practice Address - Street 2:MAB #111
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3153
Practice Address - Country:US
Practice Address - Phone:215-662-9563
Practice Address - Fax:215-243-8818
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-004744-2213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009461910001Medicaid
PA1009461910001Medicaid
080327M08Medicare PIN