Healthcare Provider Details

I. General information

NPI: 1265486500
Provider Name (Legal Business Name): MARK A. SHAMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 GULL RD SUITE 200
KALAMAZOO MI
49048-1650
US

IV. Provider business mailing address

1535 GULL RD SUITE 200
KALAMAZOO MI
49048-1650
US

V. Phone/Fax

Practice location:
  • Phone: 269-388-6350
  • Fax: 269-388-4738
Mailing address:
  • Phone: 269-388-6350
  • Fax: 269-388-4738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301072271
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number4301072271
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME162110
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301072271
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: