Provider Demographics
NPI:1942561428
Name:CHARLES J SHANLEY MD PC
Entity Type:Organization
Organization Name:CHARLES J SHANLEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-268-7391
Mailing Address - Street 1:1001 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1406
Mailing Address - Country:US
Mailing Address - Phone:313-268-7391
Mailing Address - Fax:
Practice Address - Street 1:1001 AUDUBON RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1406
Practice Address - Country:US
Practice Address - Phone:313-268-7391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010513822086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty