MEDICARE: SHANNON CLINIC

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number State
1	207K00000X	Allergy & Immunology Physician	TX
2	207KA0200X	Allergy Physician	TX
3	207L00000X	Anesthesiology Physician	TX
4	207N00000X	Dermatology Physician	TX
5	207W00000X	Ophthalmology Physician	TX
6	207X00000X	Orthopaedic Surgery Physician	TX
7	207R00000X	Internal Medicine Physician	TX
8	207T00000X	Neurological Surgery Physician	TX
9	207V00000X	Obstetrics & Gynecology Physician	TX
10	207Y00000X	Otolaryngology Physician	TX
11	207ZB0001X	Blood Banking & Transfusion Medicine Physician	TX
12	208000000X	Pediatrics Physician	TX
13	2085R0202X	Diagnostic Radiology Physician	TX
14	208600000X	Surgery Physician	TX
15	207Q00000X	Family Medicine Physician	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00T83Z	OTHER	TX	MEDICARE
3	CL8387	OTHER	TX	MEDICARE PTAN

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	127005002	OTHER	TX	CSHCN
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1770587149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANNON CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 22000
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76902-7200
Country	:	US
Telephone Number	:	325-658-1511
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 E BEAUREGARD AVE
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76903-5919
Country	:	US
Telephone Number	:	325-658-1511
Fax Number	:	325-481-2166

Authorized Official
Title or Position	:	COO
Name	:	RICARDO VILLARREAL
Credential	:
Telephone Number	:	325-747-2200

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	07/14/2025

211 CALLE MORSE
ARROYO, PR
00714-2350

Practice Phone: 787-839-3980
Practice Fax: 787-271-2515