Provider Demographics
NPI:1821072463
Name:SCOTT-VERNAGLIA, SHANNON ELLIOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ELLIOTT
Last Name:SCOTT-VERNAGLIA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS. GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST YAW 6D
Practice Address - Street 2:PEDIATRIC GROUP PRACTICE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-2728
Practice Address - Fax:617-724-3948
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MA210192208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA210192OtherTUFTS HEALTH PLAN
MAJ24685OtherBCBS OF MA
MA0168718Medicaid
I159601Medicare UPIN
MAA33662Medicare ID - Type Unspecified