1225031446 NPI number — SHANNON MEDICAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225031446 NPI number — SHANNON MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANNON MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHANNON HOME HEALTH SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225031446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3555 KNICKERBOCKER RD STE 21
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76904-7610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-747-7480
Provider Business Mailing Address Fax Number:
325-747-7497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3555 KNICKERBOCKER RD STE 21
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76904-7610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-747-7480
Provider Business Practice Location Address Fax Number:
325-747-7497
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WOOLDRIDGE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
325-657-8212

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  003134 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 023709101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4557949 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HH9647 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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