MEDICARE: SHANNON B. BEAUSOLEIL I 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	207R00000X	Internal Medicine Physician	043733	CT
2	208000000X	Pediatrics Physician	043733	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3352025	OTHER	MA	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	218498	OTHER	MA	CONNECTICARE

General Provider Information

NPI Number	:	1942291653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON B. BEAUSOLEIL I MD

Provider Business Mailing Address
First Line	:	1216 FARMINGTON AVE STE 202
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2673
Country	:	US
Telephone Number	:	860-236-0331
Fax Number	:	860-263-8697

Provider Business Practice Location Address
First Line	:	1216 FARMINGTON AVE STE 202
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2673
Country	:	US
Telephone Number	:	860-236-0331
Fax Number	:	860-263-8697

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	06/22/2021

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