Provider Demographics
NPI:1629416169
Name:SHEBAK, SHADY S (MD)
Entity Type:Individual
Prefix:DR
First Name:SHADY
Middle Name:S
Last Name:SHEBAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 PELHAM ST STE 13
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3852
Mailing Address - Country:US
Mailing Address - Phone:131-368-0080
Mailing Address - Fax:313-241-9342
Practice Address - Street 1:3815 PELHAM ST STE 13
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3852
Practice Address - Country:US
Practice Address - Phone:131-368-0080
Practice Address - Fax:313-241-9342
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011105802084A0401X, 2084P0800X, 2084P0804X, 390200000X
MI999992084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI831910484Medicaid