Basic Information
| Provider Information | |||||||||
| NPI: | 1922158997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TODD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SHANNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3125 S SCATTERFIELD RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984311 | ||||||||
| FaxNumber: | 7652984312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 34010782 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 47118 | CO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 34010782 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | 02002715A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 300014911 | 05 | IN | MEDICAID |