Provider Demographics
NPI:1194719179
Name:SHAHIN, GASSAN (MD)
Entity type:Individual
Prefix:
First Name:GASSAN
Middle Name:
Last Name:SHAHIN
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 1:18025 STONEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-4345
Mailing Address - Country:US
Mailing Address - Phone:313-570-2392
Mailing Address - Fax:
Practice Address - Street 1:18025 STONEBROOK DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-4345
Practice Address - Country:US
Practice Address - Phone:313-570-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010719182085R0202X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4846594Medicaid
MI70-0-F32947-0OtherBCBS CPIN #
MIGS071918OtherBCBSM
MII02591Medicare UPIN