Healthcare Provider Details

I. General information

NPI: 1619983897
Provider Name (Legal Business Name): THOMAS P SHANLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611
US

IV. Provider business mailing address

225 E CHICAGO AVE # 86
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4340
  • Fax: 312-227-9637
Mailing address:
  • Phone: 312-227-4340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301061940
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number4301061940
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: