Healthcare Provider Details

I. General information

NPI: 1740250448
Provider Name (Legal Business Name): MATTHEW MARVIN SHANKLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W UNIVERSITY
ROCHESTER MI
48307
US

IV. Provider business mailing address

441 S LIVERNOIS SUITE 190
ROCHESTER MI
48307-2591
US

V. Phone/Fax

Practice location:
  • Phone: 248-652-5354
  • Fax: 248-652-5407
Mailing address:
  • Phone: 248-656-9696
  • Fax: 248-656-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301053824
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: