Provider Demographics
NPI:1316194640
Name:ST CLAIRE SHORES MEDICAL PLLC
Entity Type:Organization
Organization Name:ST CLAIRE SHORES MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-293-1868
Mailing Address - Street 1:30140 HARPER AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1610
Mailing Address - Country:US
Mailing Address - Phone:586-293-1848
Mailing Address - Fax:586-293-1869
Practice Address - Street 1:30140 HARPER AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-1610
Practice Address - Country:US
Practice Address - Phone:586-293-1848
Practice Address - Fax:586-293-1869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088798261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0502329OtherBCBS
MI1417032491OtherNPI
MI70-0-F32947-0OtherBCBS CPIN#
MI4945780-10Medicaid
MI0P62160Medicare PIN
MI4945780-10Medicaid