Provider Demographics
NPI:1689614141
Name:SHANLEY, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:SHANLEY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16815 E JEFFERSON AVE STE 240
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1923
Practice Address - Country:US
Practice Address - Phone:313-473-4690
Practice Address - Fax:248-551-3023
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2020-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010513822086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery