Provider Demographics
NPI:1336594043
Name:FLEMING, SHANNON (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FLEMING
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 1:2422 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4418
Mailing Address - Country:US
Mailing Address - Phone:267-909-9555
Mailing Address - Fax:
Practice Address - Street 1:2422 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:267-909-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-01
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0013102207Q00000X
PAMD485605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty