Healthcare Provider Details

I. General information

NPI: 1427627132
Provider Name (Legal Business Name): SHANNON ROSENBROCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 10/21/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

657 PASADENA AVE
BEECHER IL
60401-3611
US

IV. Provider business mailing address

CARDIOTHORACIC AND VASCULAR SURGICAL ASSOCIATES SC 4400 W 95TH STREET SUITE 308
OAK LAWN IL
60453-2660
US

V. Phone/Fax

Practice location:
  • Phone: 815-671-9279
  • Fax:
Mailing address:
  • Phone: 708-346-4040
  • Fax: 708-346-3287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: