Provider Demographics
NPI:1316933260
Name:SHANNON, PATRICK L (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:L
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4222
Mailing Address - Country:US
Mailing Address - Phone:330-965-8760
Mailing Address - Fax:330-965-9325
Practice Address - Street 1:987 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4222
Practice Address - Country:US
Practice Address - Phone:330-965-8760
Practice Address - Fax:330-965-9325
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076264S174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH97198OtherQUALCHOICE
OH0300914OtherUNITED HEALTHCARE
OHG89588Medicare UPIN
OH97198OtherQUALCHOICE
OH4066842Medicare ID - Type UnspecifiedSALEM INDIVIDUAL