Provider Demographics
NPI:1275572570
Name:CRAFT-BLACKSHEAR, MELVA GALE (CNM)
Entity Type:Individual
Prefix:MS
First Name:MELVA
Middle Name:GALE
Last Name:CRAFT-BLACKSHEAR
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:MELVA
Other - Middle Name:GALE
Other - Last Name:BLACKSHEARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:586-228-4652
Mailing Address - Fax:586-228-4520
Practice Address - Street 1:7815 E JEFFERSON AVE
Practice Address - Street 2:SUITE 3A
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3704
Practice Address - Country:US
Practice Address - Phone:313-499-4170
Practice Address - Fax:313-499-4911
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704131538367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4702370Medicaid
MI4702360Medicaid
S00414Medicare UPIN
MA4702370Medicaid
MIP16000001Medicare ID - Type UnspecifiedMEDICARE NUMBER