Provider Demographics
NPI:1013921154
Name:SHAW, GARY H (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:H
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:STE 160
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2276
Mailing Address - Country:US
Mailing Address - Phone:231-487-3295
Mailing Address - Fax:231-487-5069
Practice Address - Street 1:416 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2212
Practice Address - Country:US
Practice Address - Phone:231-487-7303
Practice Address - Fax:231-487-7313
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301045389207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIGS045389OtherBS STATE LIC#
MI1013921154Medicaid
MI1013921154Medicaid
MIGS045389OtherBS STATE LIC#
MIB49371Medicare UPIN