Provider Demographics
NPI:1952499816
Name:SHANNON, MARY A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:121 N 20TH ST
Mailing Address - Street 2:#6
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5449
Mailing Address - Country:US
Mailing Address - Phone:334-749-3385
Mailing Address - Fax:334-742-9243
Practice Address - Street 1:121 N 20TH ST
Practice Address - Street 2:#6
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5449
Practice Address - Country:US
Practice Address - Phone:334-749-3385
Practice Address - Fax:334-742-9243
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL25078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558084Medicaid
ALI23971Medicare UPIN
AL051558084Medicare PIN