Provider Demographics
NPI:1609966670
Name:EASTPOINTE FAMILY PHYSICIANS
Entity Type:Organization
Organization Name:EASTPOINTE FAMILY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HARDIK
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-772-9055
Mailing Address - Street 1:24901 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1367
Mailing Address - Country:US
Mailing Address - Phone:586-772-9055
Mailing Address - Fax:586-772-0543
Practice Address - Street 1:24901 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1367
Practice Address - Country:US
Practice Address - Phone:586-772-9055
Practice Address - Fax:586-772-0543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010763204C00000X
MI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3439691Medicaid
MI4653079Medicaid
MI4665525Medicaid
MII18666Medicare UPIN
MI4665525Medicaid
MI0P0211002Medicare ID - Type Unspecified
MI5634778Medicare ID - Type Unspecified
MII22754Medicare UPIN
MI0P0211001Medicare ID - Type Unspecified
MI4653079Medicaid