Healthcare Provider Details

I. General information

NPI: 1932360161
Provider Name (Legal Business Name): SHANNON F.R. SMALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-3147
  • Fax: 860-865-2395
Mailing address:
  • Phone: 860-443-3147
  • Fax: 860-865-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036143686
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0101249001
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number79645
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: