Provider Demographics
NPI:1700840535
Name:LYNN, SHANNON C (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:LYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYNN
Other - Last Name:HOLDENER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:825 BARRET AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1743
Practice Address - Country:US
Practice Address - Phone:502-540-7200
Practice Address - Fax:502-540-7207
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000298643OtherANTHEM / NCMA
8634556OtherCIGNA / NCMA
KYP00107214OtherMCR - RR
1205618OtherCHA / NCMA
0000264470OtherHUMANA / NCMA
IN200447010Medicaid
023378OtherSIHO / NCMA
2443113000OtherPASSPORT ADVANTAGE / NCMA
50001528OtherPASSPORT / NCMA
KY64067911Medicaid
KY0361932Medicare PIN
0000264470OtherHUMANA / NCMA