Provider Demographics
NPI:1811993975
Name:BRAYER, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRAYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E ROYALTON RD
Mailing Address - Street 2:STE 108
Mailing Address - City:BROADVIEW HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-4038
Mailing Address - Country:US
Mailing Address - Phone:440-526-4940
Mailing Address - Fax:440-526-4885
Practice Address - Street 1:203 E ROYALTON RD
Practice Address - Street 2:STE 108
Practice Address - City:BROADVIEW HTS
Practice Address - State:OH
Practice Address - Zip Code:44147-4038
Practice Address - Country:US
Practice Address - Phone:440-526-4940
Practice Address - Fax:440-526-4885
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3152111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2248857Medicaid
9119098823A11OtherANTHEM BC/BS
7629359OtherAETNA
2802952OtherAETNA SELECT
2054628OtherUNITED HEALTHCARE
7241987OtherCIGNA 3
9119098823A11OtherANTHEM BC/BS
U89500Medicare ID - Type UnspecifiedPART B