1922158997 NPI number — DR. MICHAEL SHANNON TODD DO

Table of content: DR. MICHAEL SHANNON TODD DO (NPI 1922158997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922158997 NPI number — DR. MICHAEL SHANNON TODD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TODD
Provider First Name:
MICHAEL
Provider Middle Name:
SHANNON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1922158997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH ST STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3125 S SCATTERFIELD RD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-298-4311
Provider Business Practice Location Address Fax Number:
765-298-4312
Provider Enumeration Date:
01/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  47118 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 34010782 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 34010782 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 02002715A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300014911 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".