Healthcare Provider Details

I. General information

NPI: 1144482803
Provider Name (Legal Business Name): SHANNON FREDRICK STEWART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11705 MERCY BLVD
SAVANNAH GA
31419-1711
US

IV. Provider business mailing address

11705 MERCY BLVD
SAVANNAH GA
31419-1711
US

V. Phone/Fax

Practice location:
  • Phone: 912-656-2650
  • Fax:
Mailing address:
  • Phone: 912-656-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME162725
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number67801
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier118458800
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: