Provider Demographics
NPI:1215931787
Name:MCCARTHY, SHANNON KATHRYN (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KATHRYN
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 BROADWAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7041
Mailing Address - Country:US
Mailing Address - Phone:219-769-4371
Mailing Address - Fax:219-756-4610
Practice Address - Street 1:9001 BROADWAY
Practice Address - Street 2:SUITE D
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7041
Practice Address - Country:US
Practice Address - Phone:219-769-4371
Practice Address - Fax:219-756-4610
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-11
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031401A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC25242Medicare UPIN
IN628710Medicare PIN
IN221020JMedicare PIN