Healthcare Provider Details

I. General information

NPI: 1124433719
Provider Name (Legal Business Name): SHAUNA MARIE COSTINETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAUNA MARIE SHEPPARD M.D.

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 N CHARLES ST STE 501
BALTIMORE MD
21204-5802
US

IV. Provider business mailing address

1750 WEST HARRISON STREET GENERAL SURGERY OFFICE
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-3779
  • Fax: 443-849-3767
Mailing address:
  • Phone: 312-942-6510
  • Fax: 312-942-2867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125065618
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: