Healthcare Provider Details

I. General information

NPI: 1215059506
Provider Name (Legal Business Name): SHANNON MICHELLE DAVIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15303 S 94TH AVE STE 110
ORLAND PARK IL
60462-3825
US

IV. Provider business mailing address

3820 NORTHDALE BLVD STE 201
TAMPA FL
33624-1893
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-6117
  • Fax: 888-812-8191
Mailing address:
  • Phone: 813-280-0705
  • Fax: 813-434-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number036164424
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34.015496
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number05142
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number02003690A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036164424
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: