Provider Demographics
NPI:1871643890
Name:ANGELA P. SHANNON MD PC
Entity Type:Organization
Organization Name:ANGELA P. SHANNON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-507-0860
Mailing Address - Street 1:1129 HOSPITAL DR
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6393
Mailing Address - Country:US
Mailing Address - Phone:770-507-0860
Mailing Address - Fax:770-507-0863
Practice Address - Street 1:1129 HOSPITAL DR
Practice Address - Street 2:SUITE 3C
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6393
Practice Address - Country:US
Practice Address - Phone:770-507-0860
Practice Address - Fax:770-507-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036612084F0202X
GA0366612084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG24538Medicare UPIN
GA26BDFPCMedicare ID - Type Unspecified