Provider Demographics
NPI:1316104094
Name:SHORES MEDICAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:SHORES MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ARNOLD
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:KETELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-774-8720
Mailing Address - Street 1:25200 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-2116
Mailing Address - Country:US
Mailing Address - Phone:586-774-8720
Mailing Address - Fax:586-774-7154
Practice Address - Street 1:25200 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2116
Practice Address - Country:US
Practice Address - Phone:586-774-8720
Practice Address - Fax:586-774-7154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICK008071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty