Provider Demographics
NPI:1912065855
Name:REINBOLD, SHANNON J (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:REINBOLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4425 N PORT WASHINGTON ROAD, 3RD FLOOR
Mailing Address - Street 2:CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-326-2378
Mailing Address - Fax:414-326-2155
Practice Address - Street 1:2061 CHEYENNE COURT
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9368
Practice Address - Country:US
Practice Address - Phone:262-376-1934
Practice Address - Fax:262-375-2076
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20339-20207R00000X
WI50339-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI019940421Medicare PIN
WI462364656Medicare PIN