Basic Information
| Provider Information | |||||||||
| NPI: | 1255726618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39650 ORCHARD HILL PL STE LL-20 | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483190161 | ||||||||
| FaxNumber: | 2483190170 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 W 13 MILE RD STE LL-20 | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482882280 | ||||||||
| FaxNumber: | 2482885644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | ME148306 | FL | Y | 207WX0107X | 4301116945 | MI | N | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.