MEDICARE: SHANNON FOURTNER MD

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	2080P0205X	Pediatric Endocrinology Physician	236427	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	000528154001	OTHER	BC/BS
2	050805000017	OTHER	FIDELIS
3	1212950	OTHER	IHA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	00027224401	OTHER	UNIVERA
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225111651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON FOURTNER MD

Provider Business Mailing Address
First Line	:	8203 MAIN ST STE 14
Second Line	:
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-6051
Country	:	US
Telephone Number	:	585-201-7112
Fax Number	:	585-201-7128

Provider Business Practice Location Address
First Line	:	8203 MAIN ST STE 14
Second Line	:
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-6051
Country	:	US
Telephone Number	:	585-201-7112
Fax Number	:	585-201-7128

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

Provider Enumeration Date	:	10/21/2006
Last Update Date	:	03/07/2025

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Directions to “ SHANNON FOURTNER MD” Practice Location

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