Healthcare Provider Details

I. General information

NPI: 1962965624
Provider Name (Legal Business Name): MICHAEL JOSEPH SHALLCROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W KINNICKINNIC RIVER PKWY STE 315
MILWAUKEE WI
53215-3660
US

IV. Provider business mailing address

615 E CORCORAN AVE UNIT 241
MILWAUKEE WI
53202-4534
US

V. Phone/Fax

Practice location:
  • Phone: 414-385-2592
  • Fax: 414-385-2591
Mailing address:
  • Phone: 703-851-3647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number85628-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number85628-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101272972
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: