Basic Information
Provider Information | |||||||||
NPI: | 1528072089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHANAHAN | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 522 IDLEWILD AVE | ||||||||
Address2: |   | ||||||||
City: | EASTON | ||||||||
State: | MD | ||||||||
PostalCode: | 216013824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108225571 | ||||||||
FaxNumber: | 4108223859 | ||||||||
Practice Location | |||||||||
Address1: | 522 IDLEWILD AVE | ||||||||
Address2: |   | ||||||||
City: | EASTON | ||||||||
State: | MD | ||||||||
PostalCode: | 216013824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108225571 | ||||||||
FaxNumber: | 4108223859 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | H0064036 | MD | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | H0064036 | 01 | MD | STATE MEDICAL LICENSE | OTHER |