Provider Demographics
NPI:1790769800
Name:SHACKLEFORD, EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SHACKLEFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3043
Mailing Address - Street 2:MEA AEA KENOSH SC
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3043
Mailing Address - Country:US
Mailing Address - Phone:630-734-0200
Mailing Address - Fax:630-734-1560
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:AURORA MEDICAL CENTER
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-697-7000
Practice Address - Fax:630-734-1560
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42953021207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30099700Medicaid
G25261Medicare UPIN
WI30099700Medicaid