Provider Demographics
NPI:1740483734
Name:ELLIS, SHANNON B (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:B
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ALISE
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:800 SAINT VINCENTS DR
Mailing Address - Street 2:SUITE 500, NORTH TOWER
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1620
Mailing Address - Country:US
Mailing Address - Phone:205-933-8334
Mailing Address - Fax:205-933-8466
Practice Address - Street 1:800 SAINT VINCENTS DR
Practice Address - Street 2:SUITE 500, NORTH TOWER
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1620
Practice Address - Country:US
Practice Address - Phone:205-933-8334
Practice Address - Fax:205-933-8466
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29221207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-15776OtherBCBS
AL138048Medicaid
AL102I162519Medicare PIN