Provider Demographics
NPI:1861597742
Name:THANNUM, SHELLY L (MD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:THANNUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:L
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 171306
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187
Mailing Address - Country:US
Mailing Address - Phone:800-809-2106
Mailing Address - Fax:334-386-2037
Practice Address - Street 1:1755 KIRBY PKWY
Practice Address - Street 2:SUITE 330
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-725-5846
Practice Address - Fax:901-726-4827
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42916207L00000X
ARE4356207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157567001Medicaid
AR5N193Medicare PIN
ARP00262431Medicare PIN