1700854312 NPI number — DR. SHAWN PETER NELSON D.C.

Table of content: DR. SHAWN PETER NELSON D.C. (NPI 1700854312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700854312 NPI number — DR. SHAWN PETER NELSON D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
SHAWN
Provider Middle Name:
PETER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1700854312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 COOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE POINTE WOODS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48236-2710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-940-0294
Provider Business Mailing Address Fax Number:
949-404-8415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27200 HARPER AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48081-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-940-0294
Provider Business Practice Location Address Fax Number:
949-404-8415
Provider Enumeration Date:
03/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  SN008562 , 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: OE07214 . This is a "BCBS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4431562 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1700854312 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: SN008562 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".