Basic Information
Provider Information | |||||||||
NPI: | 1962407569 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAHESH | ||||||||
FirstName: | SHYAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NAEEM | ||||||||
OtherFirstName: | MUTHANNA | ||||||||
OtherMiddleName: | LOUIS | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 4967 CROOKS RD | ||||||||
Address2: | STE 130 | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480985801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2489521601 | ||||||||
FaxNumber: | 2489521614 | ||||||||
Practice Location | |||||||||
Address1: | 5301 E HURON RIVER DR | ||||||||
Address2: |   | ||||||||
City: | YPSILANTI | ||||||||
State: | MI | ||||||||
PostalCode: | 481971051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344640887 | ||||||||
FaxNumber: | 7344020254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2005 | ||||||||
LastUpdateDate: | 07/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301074094 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 4301074094 | MI | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 1962407569 | 01 | MI | NPI # | OTHER | SM074094 | 01 | MI | BCBSM | OTHER | 4829495 | 05 | MI |   | MEDICAID | 70-0-F32947-0 | 01 | MI | BCBS CPIN # | OTHER |