Provider Demographics
NPI:1861687675
Name:RIDDELL, SHELLY (PA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:2ND FLOOR TAUBMAN CTR RECP F
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-0332
Practice Address - Country:US
Practice Address - Phone:734-936-5738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004186363A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ04829Medicare UPIN
MIM52870083Medicare PIN