1184845331 NPI number — SPIRO AND SHANBOM MD PC

Table of content: (NPI 1184845331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184845331 NPI number — SPIRO AND SHANBOM MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPIRO AND SHANBOM MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHANBOM EYE SPECIALIST
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184845331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28747 WOODWARD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKLEY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48072-0914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-546-2133
Provider Business Mailing Address Fax Number:
248-546-6036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28747 WOODWARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKLEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48072-0914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-546-2133
Provider Business Practice Location Address Fax Number:
248-546-6036
Provider Enumeration Date:
05/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHANBOM
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
ADAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-546-2133

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301054486 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104141179 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA2010 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".