Provider Demographics
NPI:1225031446
Name:SHANNON MEDICAL CENTER
Entity type:Organization
Organization Name:SHANNON MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOLDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-657-8212
Mailing Address - Street 1:3555 KNICKERBOCKER RD STE 21
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7610
Mailing Address - Country:US
Mailing Address - Phone:325-747-7480
Mailing Address - Fax:325-747-7497
Practice Address - Street 1:3555 KNICKERBOCKER RD STE 21
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7610
Practice Address - Country:US
Practice Address - Phone:325-747-7480
Practice Address - Fax:325-747-7497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX003134251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX023709101Medicaid
TX4557949OtherAETNA
TXHH9647OtherBLUE CROSS
TX023709101Medicaid