Healthcare Provider Details

I. General information

NPI: 1720280175
Provider Name (Legal Business Name): SHANNON GRACE FARMAKIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON GRACE LEHNER MD

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date: 07/17/2007
Reactivation Date: 02/28/2008

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

11475 OLDE CABIN RD STE 200
SAINT LOUIS MO
63141-7129
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6031
  • Fax: 314-251-6343
Mailing address:
  • Phone: 314-991-8200
  • Fax: 314-991-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberM-14782
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMD60962082
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0444325
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-14782
License Number StateID
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number200813456
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: