Basic Information
| Provider Information | |||||||||
| NPI: | 1073197562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | SHALIMAR | ||||||||
| MiddleName: | MOGHUL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29225 SUNRIDGE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483344012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488196943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488985000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2021 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704263051 | MI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.