Basic Information
| Provider Information | |||||||||
| NPI: | 1457511040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIH | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | PHU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHU | ||||||||
| OtherFirstName: | JENNY | ||||||||
| OtherMiddleName: | YEE-NGOI | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7700 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132028660 | ||||||||
| FaxNumber: | 3132028653 | ||||||||
| Practice Location | |||||||||
| Address1: | 21040 GREENFIELD RD | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482373025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489676538 | ||||||||
| FaxNumber: | 2489676552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101017681 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700H231390 | 01 | MI | BCBS GROUP NUMBER | OTHER |