Provider Demographics
NPI:1992750681
Name:SHELLEY FREIMARK, MD, PLC
Entity type:Organization
Organization Name:SHELLEY FREIMARK, MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FREIMARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-296-1143
Mailing Address - Street 1:11257 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11257 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8825
Practice Address - Country:US
Practice Address - Phone:616-566-3379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066173208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104813584Medicaid
MI2507011161OtherBCBSM MI
MISF066173OtherSTATE LICENSE#
MI2507011161OtherBCBSM MI
MIH04300Medicare UPIN