Provider Demographics
NPI:1235110289
Name:SHORES DIAGNOSTIC LLC
Entity Type:Organization
Organization Name:SHORES DIAGNOSTIC LLC
Other - Org Name:SHORES DIAGNOSTIC PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GULAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHIUDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-285-8728
Mailing Address - Street 1:9800 CONANT ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3309
Mailing Address - Country:US
Mailing Address - Phone:313-285-8728
Mailing Address - Fax:313-784-9055
Practice Address - Street 1:9800 CONANT ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3309
Practice Address - Country:US
Practice Address - Phone:313-285-8728
Practice Address - Fax:313-784-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114769270Medicaid
MI104763590Medicaid
MI104763580Medicaid
MI310E017130OtherBCBS OF MICHIGAN
MI104763580Medicaid