Healthcare Provider Details

I. General information

NPI: 1215490776
Provider Name (Legal Business Name): SHANNON MARIE PHILIPPS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 HIGHWAY 17 N
SURFSIDE BEACH SC
29575-6012
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD ATTENTION CREDENTIALING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-8041
  • Fax: 843-347-8042
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number93574
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: