Provider Demographics
NPI:1336386028
Name:SHANNON MEDICAL CENTER
Entity Type:Organization
Organization Name:SHANNON MEDICAL CENTER
Other - Org Name:SHANNON MEDICAL CENTER - OUTPATIENT DIALYSIS FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-657-5031
Mailing Address - Street 1:PO BOX 1879
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-1879
Mailing Address - Country:US
Mailing Address - Phone:325-653-6741
Mailing Address - Fax:
Practice Address - Street 1:2018 PULLIAM ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76905-5148
Practice Address - Country:US
Practice Address - Phone:325-653-6741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANNON MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-16
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00168261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148371103Medicaid
TX148371103Medicaid