1760677389 NPI number — MRS. MICHELLE LYNN SHRADER MPT

Table of content: MRS. MICHELLE LYNN SHRADER MPT (NPI 1760677389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760677389 NPI number — MRS. MICHELLE LYNN SHRADER MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHRADER
Provider First Name:
MICHELLE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BARTLETT
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760677389
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33900 HARPER AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48035-4258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-416-9100
Provider Business Mailing Address Fax Number:
586-416-9103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4245 W 14 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48073-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-554-9201
Provider Business Practice Location Address Fax Number:
248-554-9202
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501011295 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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