Provider Demographics
NPI:1801862677
Name:RIEGLE, SHANNON D (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:RIEGLE
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 1:940 PARK EAST BLVD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905
Mailing Address - Country:US
Mailing Address - Phone:765-464-2280
Mailing Address - Fax:
Practice Address - Street 1:940 PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0792
Practice Address - Country:US
Practice Address - Phone:765-464-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044327A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200149450Medicaid
IN000000766379OtherANTHEM
ING25140Medicare UPIN
INM400070677Medicare PIN