Basic Information
| Provider Information | |||||||||
| NPI: | 1215059506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11595 N MERIDIAN ST STE 375 | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460323950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175757304 | ||||||||
| FaxNumber: | 3175757333 | ||||||||
| Practice Location | |||||||||
| Address1: | 4850 RED BANK RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452271545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132212544 | ||||||||
| FaxNumber: | 5132211320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 02003690A | IN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 34.015496 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 05142 | KY | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100787770 | 05 | KY | MEDICAID | 200992420 | 05 | IN | MEDICAID | 0470386 | 05 | OH | MEDICAID |