Provider Demographics
NPI:1780681627
Name:SHANAHAN, THERESA L (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:SHANAHAN
Suffix:
Gender:F
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:PO BOX 9120
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02027-9120
Mailing Address - Country:US
Mailing Address - Phone:781-329-1400
Mailing Address - Fax:781-278-5667
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:781-329-1400
Practice Address - Fax:781-278-5667
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206175208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1240820OtherUNITED HEALTHCARE
204130OtherHARVARD PILGRIM PPO
0023152OtherNEIGHBORHOOD HEALTH
206175OtherTUFTS
0141330OtherMASS HEALTH
204130OtherFIRST SENIORITY
204130OtherHARVARD PILGRIM POS
206175OtherTUFTS COMMONWEALTH PPO
27697OtherCHILDREN'S MED SECURITY
J23933OtherHMO BLUE/BLUE CHOICE
204130OtherHARVARD PILGRIM
MA2780341OtherHEALTHSOURCE
J23933OtherBS-BLUE CARE ELECT
206175OtherTUFTS TOTAL HEALTH PLAN
2780341OtherCIGNA HEALTH CARE
J23933OtherBLUE SHIELD INDEMNITYY
204130OtherHARVARD PILGRIM POS