Provider Demographics
NPI:1437385382
Name:AGELOFF-KUPETZ, SHANA A (MD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:A
Last Name:AGELOFF-KUPETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3235 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3971
Mailing Address - Country:US
Mailing Address - Phone:517-787-3280
Mailing Address - Fax:517-787-9680
Practice Address - Street 1:3235 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3971
Practice Address - Country:US
Practice Address - Phone:517-787-3280
Practice Address - Fax:517-787-9680
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301097152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45592OtherSTATE LICENSE
MI080G31660OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI185245OtherGREAT LAKES HREALTH PLAN OF MICHIGAN
MO381908328OtherHCAP
MI1437385382Medicaid
MI381908328OtherPRIORITY HEALTH
MI1437385382OtherMOLINA HEALTH PLAN OF MICHIGAN
MI381908328470OtherCARE SOURCE OF MICHIGAN
MI1062975OtherMCLAREN HEALTH PLAN
MI0G36111143Medicare PIN