Provider Demographics
NPI:1285756643
Name:SHELBY MACOMB FAMILY PRACTICE, P.C.
Entity type:Organization
Organization Name:SHELBY MACOMB FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-228-0200
Mailing Address - Street 1:42500 HAYES RD SUITE 800
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6761
Mailing Address - Country:US
Mailing Address - Phone:586-228-0200
Mailing Address - Fax:
Practice Address - Street 1:42500 HAYES RD SUITE 800
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6761
Practice Address - Country:US
Practice Address - Phone:586-228-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty