1225182637 NPI number — SHANNON M GULLA M.D.

Table of content: SHANNON M GULLA M.D. (NPI 1225182637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225182637 NPI number — SHANNON M GULLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GULLA
Provider First Name:
SHANNON
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
SHANNON
Provider Other Middle Name:
LYNETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225182637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5083
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38101-5083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-448-8679
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 WOLF RIVER BLVD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138-1784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-747-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2007

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: 2085R0202X , with the licence number:  2008-00055 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: E-5160 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 42013 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: 18706 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5910379 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".