Provider Demographics
NPI:1740240035
Name:SHELBY-LANE, CYNTHIA A (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:A
Last Name:SHELBY-LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29488 WOODWARD AVE
Mailing Address - Street 2:#177
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0903
Mailing Address - Country:US
Mailing Address - Phone:800-584-4926
Mailing Address - Fax:
Practice Address - Street 1:29488 WOODWARD AVE
Practice Address - Street 2:#177
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0903
Practice Address - Country:US
Practice Address - Phone:313-492-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A74626Medicare UPIN
N98390006Medicare ID - Type Unspecified