MEDICARE: DOMINIK ALAN SHANNON PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT013656	GA

General Provider Information

NPI Number	:	1114409273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIK ALAN SHANNON PT, DPT

Provider Business Mailing Address
First Line	:	6397 LEE HWY STE 300
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-2564
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-362-8684

Provider Business Practice Location Address
First Line	:	842 N HIGHLAND AVE NE STE TER
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-4530
Country	:	US
Telephone Number	:	678-685-9356
Fax Number	:	678-685-9357

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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