Provider Demographics
NPI:1780891176
Name:ARMSTRONG, SHANNON DALE (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DALE
Last Name:ARMSTRONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 CHERRY STREET
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4607
Mailing Address - Country:US
Mailing Address - Phone:616-459-4131
Mailing Address - Fax:616-459-6030
Practice Address - Street 1:245 CHERRY STREET S.E.
Practice Address - Street 2:SUITE 302
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-459-4131
Practice Address - Fax:616-459-6030
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088227208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D16253021Medicare PIN