Basic Information
| Provider Information | |||||||||
| NPI: | 1922368331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142935123 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3691 RIDGE MILL DR | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146889220 | ||||||||
| FaxNumber: | 6146889177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 02004854A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 02004854A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 5101019944 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 34013697 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0336853 | 05 | OH | MEDICAID |