Basic Information
| Provider Information | |||||||||
| NPI: | 1295716348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALLEY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | HILLMAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N 12TH ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028396968 | ||||||||
| FaxNumber: | 6028394144 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 N 12TH ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028396968 | ||||||||
| FaxNumber: | 6028394144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 08/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4227 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 457300 | 05 | AZ | MEDICAID | 860373636 | 01 | AZ | HUMANA GRP # | OTHER | 3981220 | 01 | AZ | EVERCARE GRP # | OTHER | AW1436 | 01 | AZ | HEALTHNET GRP # | OTHER | AZ0728670 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER | 453051001 | 01 | GROUP HEALTH GRP # | OTHER |