Healthcare Provider Details

I. General information

NPI: 1477518793
Provider Name (Legal Business Name): TIMOTHY RAY SHANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 BROOKMAN DR
BROOKHAVEN MS
39601-2326
US

IV. Provider business mailing address

509 BROOKMAN DR
BROOKHAVEN MS
39601-2326
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-5204
  • Fax: 601-833-1224
Mailing address:
  • Phone: 601-823-5204
  • Fax: 601-833-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21817
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: