Healthcare Provider Details

I. General information

NPI: 1063597540
Provider Name (Legal Business Name): SHANNON J GRAEWIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 N PORT WASHINGTON ROAD SUITE 151
MILWAUKEE WI
53217-5453
US

IV. Provider business mailing address

5150 N PORT WASHINGTON ROAD SUITE 151
MILWAUKEE WI
53217-5453
US

V. Phone/Fax

Practice location:
  • Phone: 414-332-1000
  • Fax: 414-332-1005
Mailing address:
  • Phone: 414-332-1000
  • Fax: 414-332-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number45794-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number45794
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: