Provider Demographics
NPI:1619906930
Name:SHANKS, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:SHANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10335 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5763
Mailing Address - Country:US
Mailing Address - Phone:262-240-9870
Mailing Address - Fax:262-240-9869
Practice Address - Street 1:3100 SHORE DR
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4242
Practice Address - Country:US
Practice Address - Phone:715-735-4200
Practice Address - Fax:715-735-8019
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43866-0202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34304300Medicaid
F02476Medicare UPIN