Provider Demographics
NPI:1023067550
Name:SWANSON, SHANNON (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:330-493-4443
Mailing Address - Fax:330-493-8677
Practice Address - Street 1:158 W MAIN RD
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-2039
Practice Address - Country:US
Practice Address - Phone:330-493-4443
Practice Address - Fax:330-493-8677
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008887207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000385522OtherANTHEM
OH000000383091OtherANTHEM
OH101986736-0001OtherPENNSYLVANIA MEDICAID
OH2708994Medicaid
OHP00400166Medicare PIN
OHP00383000Medicare PIN
OH000000385522OtherANTHEM
OHSW4204182Medicare PIN
OH000000383091OtherANTHEM