Provider Demographics
NPI:1861451262
Name:NEITZEL, SHELLY J (MD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:J
Last Name:NEITZEL
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 1:2038 NORWAY RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-3645
Mailing Address - Country:US
Mailing Address - Phone:734-904-0301
Mailing Address - Fax:
Practice Address - Street 1:2038 NORWAY RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-3645
Practice Address - Country:US
Practice Address - Phone:734-904-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISN053407207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI423964010Medicaid
MIG39340Medicare UPIN
MI0M88740006Medicare ID - Type Unspecified