Healthcare Provider Details

I. General information

NPI: 1134107105
Provider Name (Legal Business Name): WENDELL K SHANNON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W HOBBS ST
ATHENS AL
35611-2333
US

IV. Provider business mailing address

PO BOX 1104
ATHENS AL
35612-1104
US

V. Phone/Fax

Practice location:
  • Phone: 256-216-9777
  • Fax: 256-216-9776
Mailing address:
  • Phone: 256-216-9777
  • Fax: 256-216-9776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7268
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: