Provider Demographics
NPI:1295716348
Name:SMALLEY, SHANNON HILLMAN (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:HILLMAN
Last Name:SMALLEY
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 1:1300 N 12TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-839-6968
Mailing Address - Fax:602-839-4144
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-839-6968
Practice Address - Fax:602-839-4144
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4227207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ457300Medicaid
AZ860373636OtherHUMANA GRP #
AZ3981220OtherEVERCARE GRP #
AZAW1436OtherHEALTHNET GRP #
AZAZ0728670OtherBLUE CROSS BLUE SHIELD
453051001OtherGROUP HEALTH GRP #
AZ457300Medicaid
453051001OtherGROUP HEALTH GRP #