Basic Information
| Provider Information | |||||||||
| NPI: | 1245429281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARY H. SHAW, M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | STE 505 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872100 | ||||||||
| FaxNumber: | 2314876049 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | STE 505 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872100 | ||||||||
| FaxNumber: | 2314876049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2007 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2314872100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 4301045389 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 104092118 | 05 | MI | MEDICAID |