Basic Information
| Provider Information | |||||||||
| NPI: | 1477748648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDSMITH | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014772014 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 822 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ELLISVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394372425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014772014 | ||||||||
| FaxNumber: | 6014779942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34009767 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 24285 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07854358 | 05 | MS | MEDICAID | 12114080 | 01 | OH | CAQH | OTHER | 3056277 | 05 | OH | MEDICAID | 0236248 | 05 | OH | MEDICAID |