Provider Demographics
NPI:1558684787
Name:SHELBY MACOMB PEDIATRICS P C
Entity Type:Organization
Organization Name:SHELBY MACOMB PEDIATRICS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAMIS
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:586-991-0720
Mailing Address - Street 1:PO BOX 33726
Mailing Address - Street 2:DEPT 999305
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-3726
Mailing Address - Country:US
Mailing Address - Phone:810-720-5715
Mailing Address - Fax:810-732-0891
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:SUITE 250
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-991-0720
Practice Address - Fax:586-991-0723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10582OtherBCBSM
MI080E009340OtherBCBSM/BCN
MIMI2750Medicare PIN