Provider Demographics
NPI:1568415677
Name:SHEULY, JOBEDA (MD)
Entity Type:Individual
Prefix:
First Name:JOBEDA
Middle Name:
Last Name:SHEULY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1414
Mailing Address - Country:US
Mailing Address - Phone:616-323-3999
Mailing Address - Fax:616-552-1618
Practice Address - Street 1:1740 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-1414
Practice Address - Country:US
Practice Address - Phone:616-323-3999
Practice Address - Fax:616-552-1618
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4876726Medicaid
MI4773489Medicaid
MI4773504Medicaid
MI4773498Medicaid
MIP32930011Medicare ID - Type Unspecified
MII36619Medicare UPIN
MIM02830140Medicare ID - Type Unspecified
MI4773504Medicaid