Basic Information
| Provider Information | |||||||||
| NPI: | 1205836137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHATIWALA | ||||||||
| FirstName: | SHYLAJA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 851 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344535100 | ||||||||
| FaxNumber: | 7344533538 | ||||||||
| Practice Location | |||||||||
| Address1: | 851 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344535100 | ||||||||
| FaxNumber: | 7344533538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | SK076421 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11438804 | 01 | MI | CAQH | OTHER | 1205836137 | 01 | MI | BCBS TYPE 1 (IND) NPI # | OTHER | 4301076421 | 01 | MI | STATE LICENSE # | OTHER | 5315052867 | 01 | MI | CDS # | OTHER | P37000001 | 01 | MI | MEDICARE IND PIN # | OTHER |