Provider Demographics
NPI:1114383775
Name:SHANNON, COLLEEN MORAN (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MORAN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3401 CIVIC CENTER BLVD RM 55
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4319
Mailing Address - Country:US
Mailing Address - Phone:215-590-1220
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD RM 55
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM-650-122-792-658390200000X
PAMT217671208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program