Healthcare Provider Details

I. General information

NPI: 1962738856
Provider Name (Legal Business Name): SHANNON EILEEN STALEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

1727 N HERMITAGE AVE APT #2
CHICAGO IL
60622-1411
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone: 708-363-1328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125056477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: