Healthcare Provider Details

I. General information

NPI: 1689614141
Provider Name (Legal Business Name): CHARLES J SHANLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16815 E JEFFERSON AVE STE 240
GROSSE POINTE MI
48230-1923
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-473-4690
  • Fax: 248-551-3023
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301051382
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: