| Shelbydale Medical Clinic, P.c. | |
|
49221 Van Dyke Ave Shelby Twp MI 48317-1336 | |
| (586) 254-4860 | |
| (586) 254-5844 |
| Full Name | Shelbydale Medical Clinic, P.c. |
|---|---|
| Speciality | Family Medicine |
| Location | 49221 Van Dyke Ave, Shelby Twp, Michigan |
| Authorized Official Name and Position | Keith B Tom (PRESIDENT) |
| Authorized Official Contact | 5862544860 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Shelbydale Medical Clinic, P.c. 49221 Van Dyke Ave Shelby Twp MI 48317-1336 Ph: (586) 254-4860 | Shelbydale Medical Clinic, P.c. 49221 Van Dyke Ave Shelby Twp MI 48317-1336 Ph: (586) 254-4860 |
| NPI Number | 1629258488 |
|---|---|
| Provider Enumeration Date | 11/09/2007 |
| Last Update Date | 11/09/2007 |
| Medicare PECOS PAC ID | 4880651405 |
|---|---|
| Medicare Enrollment ID | O20041215000750 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629258488 | NPI | - | NPPES |
| 2646558 | Medicaid | MI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | KT008999 (Michigan) | Primary |
| Provider Name | Keith Brian Tom |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1609850130 PECOS PAC ID: 1052378676 Enrollment ID: I20041215000775 |
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