Provider Demographics
NPI:1720069636
Name:SHAGRIN, JEROLD W (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROLD
Middle Name:W
Last Name:SHAGRIN
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 1:1695 W 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2100
Mailing Address - Country:US
Mailing Address - Phone:248-548-9090
Mailing Address - Fax:248-548-8462
Practice Address - Street 1:1695 W 12 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2100
Practice Address - Country:US
Practice Address - Phone:248-548-9090
Practice Address - Fax:248-548-8462
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027957207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F37128048OtherBCBSM PIN
MI0F37128048OtherBCBSM PIN
A73763Medicare UPIN