Provider Demographics
NPI:1417032491
Name:SHELTON, BERNARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:W
Last Name:SHELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
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:586-293-1868
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:586-293-1868
Practice Address - Fax:586-293-1869
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088798207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI70-0-F32947-0OtherBCBS CPIN #
MI4945780-10Medicaid
MI1417032491OtherNPI #
MIP28070078Medicare PIN
MII65509Medicare UPIN