Provider Demographics
NPI:1679505804
Name:SHIAWASSEE PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SHIAWASSEE PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EKRAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-723-9796
Mailing Address - Street 1:208 N SHIAWASSEE ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867
Mailing Address - Country:US
Mailing Address - Phone:989-723-9796
Mailing Address - Fax:989-729-4032
Practice Address - Street 1:208 N SHIAWASSEE ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2755
Practice Address - Country:US
Practice Address - Phone:989-723-9796
Practice Address - Fax:989-725-2383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0807800101OtherBLUE CROSS
MI3940611Medicaid
MI1679505804Medicaid
MI3940611Medicaid
MI0M67320Medicare Oscar/Certification