1174767677 NPI number — SHANNON L TENNANT PT

Table of content: SHANNON L TENNANT PT (NPI 1174767677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174767677 NPI number — SHANNON L TENNANT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TENNANT
Provider First Name:
SHANNON
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1174767677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 JACKSON PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLIPOLIS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45631-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-992-0060
Provider Business Mailing Address Fax Number:
740-446-5154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
88 EAST MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMEROY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-992-0060
Provider Business Practice Location Address Fax Number:
740-446-5154
Provider Enumeration Date:
04/28/2009

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: 225100000X , with the licence number:  012394 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1174767677 . This is a "MED MUTAL OF OHIO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000270651 . This is a "OH MEDICAID UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 3810014932 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2970129 . This is a "OH MEDICAID MOLINA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2970129 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00794068 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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