Healthcare Provider Details

I. General information

NPI: 1275762429
Provider Name (Legal Business Name): LARRY ROLAND SHANNON II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7444 HANNOVER PKWY S STE 225
STOCKBRIDGE GA
30281-7847
US

IV. Provider business mailing address

7444 HANNOVER PKWY S STE 225
STOCKBRIDGE GA
30281-7847
US

V. Phone/Fax

Practice location:
  • Phone: 404-882-3592
  • Fax: 404-891-9299
Mailing address:
  • Phone: 404-882-3592
  • Fax: 404-891-9299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number102882
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036.121453
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberD72508
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: