MEDICARE: SHANNON MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	003134	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4557949	OTHER	TX	AETNA
3	HH9647	OTHER	TX	BLUE CROSS

General Provider Information

NPI Number	:	1225031446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANNON MEDICAL CENTER

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

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

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	08/02/2023

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Directions to “SHANNON MEDICAL CENTER ” Practice Location

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