Healthcare Provider Details

I. General information

NPI: 1740273630
Provider Name (Legal Business Name): P MICHAEL SHATTUCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PAUL SHATTUCK MD

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

IV. Provider business mailing address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5538
  • Fax: 920-361-5499
Mailing address:
  • Phone: 920-361-1313
  • Fax: 920-361-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25430-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25430-020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25430
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: