Healthcare Provider Details

I. General information

NPI: 1225487499
Provider Name (Legal Business Name): BRYANT CHRISTOPHER SHANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2179
  • Fax:
Mailing address:
  • Phone: 207-662-2179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD28578
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number92333
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number92333
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD28578
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: