Basic Information
| Provider Information | |||||||||
| NPI: | 1710373139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301501177 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.