Basic Information
| Provider Information | |||||||||
| NPI: | 1629110804 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHORES PRIMARY CARE, P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 28001 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867727180 | ||||||||
| FaxNumber: | 5862790033 | ||||||||
| Practice Location | |||||||||
| Address1: | 28001 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867727180 | ||||||||
| FaxNumber: | 5862790033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARNETT | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5867727180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0N67900 | 01 | MI | HAP,OUT OF NETWORK | OTHER | E83365 | 01 | MI | HEALTH CHOICE HAP | OTHER | 4541715 | 05 | MI | MEDICAID | 022739 | 01 | MI | MIDWEST HEALTH PLAN | OTHER | 107599PC | 01 | MI | CARE CHOICES | OTHER | 4541715 | 01 | MI | MOLINA HEALTH CARE OF MI | OTHER | 0004122882 | 01 | MI | AETNA | OTHER | 022739 | 01 | MI | MIDWEST MEDICARE ADVANTAG | OTHER | 141770 | 01 | MI | GREAT LAKES HEALTH PLAN | OTHER | E83365 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER | 700EO0079-0 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |