Individual
EDWARD SHACKLEFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
10400 75TH ST, AURORA MEDICAL CENTER, KENOSHA, WI 53142-7884
(262) 697-7000
(630) 734-1560
Mailing address
PO BOX 3043, MEA AEA KENOSH SC, OAK BROOK, IL 60522-3043
(630) 734-0200
(630) 734-1560
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
42953021
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
30099700
—
WI
Enumeration date
12/01/2005
Last updated
07/08/2007
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