Provider Demographics
NPI:1740273630
Name:SHATTUCK, P MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:P
Middle Name:MICHAEL
Last Name:SHATTUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:SHATTUCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-1313
Mailing Address - Fax:920-361-5499
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5538
Practice Address - Fax:920-361-5499
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25430-020207Q00000X, 208600000X
WI25430207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30668600Medicaid
WI30668600Medicaid
WI008500416Medicare PIN