Provider Demographics
NPI:1326890666
Name:LOON LAKE PRIMARY CARE
Entity Type:Organization
Organization Name:LOON LAKE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHABOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-833-6343
Mailing Address - Street 1:1545 N WIXOM RD
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-1411
Mailing Address - Country:US
Mailing Address - Phone:248-833-6343
Mailing Address - Fax:248-833-6343
Practice Address - Street 1:1545 N WIXOM RD
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-1411
Practice Address - Country:US
Practice Address - Phone:248-833-6343
Practice Address - Fax:248-833-6343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-02
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty