1184816092 NPI number — DAVID M. SHEPHERD MD PC

Table of content: (NPI 1184816092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184816092 NPI number — DAVID M. SHEPHERD MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID M. SHEPHERD 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:
Provider Other Organization Name Type Code:
6
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:
1184816092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41935 W 12 MILE RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48377-3111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-347-8030
Provider Business Mailing Address Fax Number:
248-305-6694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41935 W 12 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48377-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-347-8030
Provider Business Practice Location Address Fax Number:
248-305-6694
Provider Enumeration Date:
08/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPHERD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-347-8030

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  32402 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X , with the licence number: 32402 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DE3726 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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