Healthcare Provider Details

I. General information

NPI: 1942593876
Provider Name (Legal Business Name): MARYANN M. SHANGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CHERRY ST SE
GRAND RAPIDS MI
49503-4608
US

IV. Provider business mailing address

PO BOX 776974
CHICAGO IL
60677-6974
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5600
  • Fax: 616-685-6745
Mailing address:
  • Phone: 616-685-1808
  • Fax: 312-957-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD60739968
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301098522
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD198359
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301098522
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: