MEDICARE: SHOSHANA DEANN HALLOWELL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	ME126441	FL
2	208600000X	Surgery Physician	4301500635	MI

General Provider Information

NPI Number	:	1528371895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHOSHANA DEANN HALLOWELL M.D.

Provider Business Mailing Address
First Line	:	1400 SE GOLDTREE DR
Second Line	:	SUITE 102-104
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-7582
Country	:	US
Telephone Number	:	772-335-8446
Fax Number	:	772-335-8499

Provider Business Practice Location Address
First Line	:	29000 LITTLE MACK AVE STE B
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48081-3018
Country	:	US
Telephone Number	:	586-774-8811
Fax Number	:	586-541-0199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2010
Last Update Date	:	06/28/2021

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