Provider Demographics
NPI:1003955618
Name:SHANLEY, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SHANLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5339
Mailing Address - Country:US
Mailing Address - Phone:888-646-7763
Mailing Address - Fax:866-344-3934
Practice Address - Street 1:800 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2349
Practice Address - Country:US
Practice Address - Phone:847-618-4177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112847207P00000X
IL036-112847207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112847Medicaid