1871784702 NPI number — SHAUNA RYDER DIGGS MD PC

Table of content: (NPI 1871784702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871784702 NPI number — SHAUNA RYDER DIGGS MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAUNA RYDER DIGGS 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:
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:
1871784702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36293
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE POINTE FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48236-0293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-822-5777
Provider Business Mailing Address Fax Number:
313-882-5776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17000 KERCHEVAL AVE
Provider Second Line Business Practice Location Address:
STE 215
Provider Business Practice Location Address City Name:
GROSSE POINTE PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48230-1570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-822-5777
Provider Business Practice Location Address Fax Number:
313-882-5776
Provider Enumeration Date:
08/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIGGS
Authorized Official First Name:
SHAUNA
Authorized Official Middle Name:
RYDER
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
313-882-5777

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  4301064244 , 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)





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