Provider Demographics
NPI:1316051949
Name:RADGENS, SHANNON THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:THOMAS
Last Name:RADGENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 W KING ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2116
Mailing Address - Country:US
Mailing Address - Phone:989-729-4800
Mailing Address - Fax:989-729-4810
Practice Address - Street 1:818 W KING ST
Practice Address - Street 2:SUITE 301
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2116
Practice Address - Country:US
Practice Address - Phone:989-729-4800
Practice Address - Fax:989-729-4810
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013241207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4616511Medicaid
MIH48637Medicare UPIN
MIN94650Medicare ID - Type Unspecified