Provider Demographics
NPI:1740250448
Name:SHANKLE, MATTHEW MARVIN (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MARVIN
Last Name:SHANKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S LIVERNOIS
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2591
Mailing Address - Country:US
Mailing Address - Phone:248-656-9696
Mailing Address - Fax:248-656-5731
Practice Address - Street 1:1101 W UNIVERSITY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-652-5354
Practice Address - Fax:248-652-5407
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053824207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102903575Medicaid
MI102903575Medicaid
F36094009Medicare ID - Type Unspecified