Provider Demographics
NPI:1578583472
Name:SHALINI GUPTA, M.D., P.C.
Entity Type:Organization
Organization Name:SHALINI GUPTA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-292-7700
Mailing Address - Street 1:47753 SEVEN MILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167
Mailing Address - Country:US
Mailing Address - Phone:248-842-3221
Mailing Address - Fax:
Practice Address - Street 1:25500 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3926
Practice Address - Country:US
Practice Address - Phone:313-292-1300
Practice Address - Fax:313-292-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067982207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4264114 TYPE 10Medicaid
MIOP33420Medicare PIN
H06923Medicare UPIN
MI4264114 TYPE 10Medicaid