Provider Demographics
NPI:1669869061
Name:SHUBERT, BIANCA M
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:M
Last Name:SHUBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BIANCA
Other - Middle Name:MARIE
Other - Last Name:WHITTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-219-2000
Mailing Address - Fax:414-219-6650
Practice Address - Street 1:945 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1305
Practice Address - Country:US
Practice Address - Phone:414-219-2000
Practice Address - Fax:414-219-6650
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000057436207P00000X
WI72247207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100096514Medicaid