Healthcare Provider Details

I. General information

NPI: 1588306765
Provider Name (Legal Business Name): SHANITA MARIE THOMAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

221 MICHIGAN ST NE STE 400
GRAND RAPIDS MI
49503-2538
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-4578
  • Fax:
Mailing address:
  • Phone: 616-267-8244
  • Fax: 616-267-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number4301514851
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: