Provider Demographics
NPI:1154577419
Name:SHELLY L WILLIAMS, DO PLLC
Entity type:Organization
Organization Name:SHELLY L WILLIAMS, DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-719-0798
Mailing Address - Street 1:318 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-3113
Mailing Address - Country:US
Mailing Address - Phone:231-719-0798
Mailing Address - Fax:231-744-8570
Practice Address - Street 1:318 CENTER ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3113
Practice Address - Country:US
Practice Address - Phone:231-719-0798
Practice Address - Fax:231-744-8570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009366261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01260001OtherMEDICARE INDIVIDUAL NUMBER
MI4736780Medicaid
1205859956OtherINDIVIDUAL NPI NUMBER
E26792Medicare UPIN
P01260001OtherMEDICARE INDIVIDUAL NUMBER