Provider Demographics
NPI:1700948072
Name:SHORT, MICHAEL JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JONATHAN
Last Name:SHORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42505 WOODWARD AVE.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5147
Mailing Address - Country:US
Mailing Address - Phone:248-334-6200
Mailing Address - Fax:248-334-3660
Practice Address - Street 1:42505 WOODWARD AVE.
Practice Address - Street 2:SUITE 103
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5147
Practice Address - Country:US
Practice Address - Phone:248-334-6200
Practice Address - Fax:248-334-3660
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010294122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0638423OtherBLUE CROSS,OTHER INSURACE
MI1065073-10-0Medicaid
MI0638423OtherBLUE CROSS,OTHER INSURACE
MI0638423Medicare ID - Type Unspecified