Provider Demographics
NPI:1578819850
Name:MAWAN SHUAYTO MD PC
Entity Type:Organization
Organization Name:MAWAN SHUAYTO MD PC
Other - Org Name:BLUE WATER OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARWAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:SHUAYTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-989-0000
Mailing Address - Street 1:615 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5400
Mailing Address - Country:US
Mailing Address - Phone:810-989-0000
Mailing Address - Fax:
Practice Address - Street 1:1201 STONE ST
Practice Address - Street 2:SUITE 8
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3563
Practice Address - Country:US
Practice Address - Phone:810-989-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAWAN SHUAYTO MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-24
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI167576Medicare UPIN