Provider Demographics
NPI:1164739066
Name:MICHIGAN PHYSICIANS GROUP, PC
Entity Type:Organization
Organization Name:MICHIGAN PHYSICIANS GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DINESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-583-0100
Mailing Address - Street 1:30855 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-5213
Mailing Address - Country:US
Mailing Address - Phone:248-583-0100
Mailing Address - Fax:248-583-4894
Practice Address - Street 1:2025 W LONG LAKE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-4100
Practice Address - Country:US
Practice Address - Phone:248-952-1540
Practice Address - Fax:248-541-6862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065276207RC0000X
MI43010664692084N0400X
MI5315028842213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF36177OtherBCBSM
6388420003OtherMEDICARE DME PTAN
MIOF36177Medicare PIN