1750596672 NPI number — DR. WILLIAM ABRAHAM SHAHEEN III O.D.

Table of content: DR. WILLIAM ABRAHAM SHAHEEN III O.D. (NPI 1750596672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750596672 NPI number — DR. WILLIAM ABRAHAM SHAHEEN III O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAHEEN
Provider First Name:
WILLIAM
Provider Middle Name:
ABRAHAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
O.D.
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:
1750596672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8598 LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE ILE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48138-1957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-675-2079
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10531 W JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVER ROUGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48218-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-841-5060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2007

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: 152W00000X , with the licence number:  4901003733 , 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: 3475571 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5287400001 . This is a "MEDICARE DME NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: 900H202090 . This is a "BLUE CROSS PROVIDER NO." identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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