Provider Demographics
NPI:1508852765
Name:SHAH, HARDIK M (DO)
Entity Type:Individual
Prefix:MR
First Name:HARDIK
Middle Name:M
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 MARSEILLES ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1479
Mailing Address - Country:US
Mailing Address - Phone:313-290-2250
Mailing Address - Fax:313-290-2257
Practice Address - Street 1:4300 MARSEILLES ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1479
Practice Address - Country:US
Practice Address - Phone:313-290-2250
Practice Address - Fax:313-290-2257
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010763204D00000X
MIHS010763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383397259OtherTAX IDENTIFICATION
MI3439691Medicaid
MI1285717249Medicaid
MI3439691Medicaid
MIMI4989Medicare PIN
MI383397259OtherTAX IDENTIFICATION
MIMI4534Medicare PIN