Basic Information
| Provider Information | |||||||||
| NPI: | 1750399655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHADEL | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888618740 | ||||||||
| FaxNumber: | 8662506385 | ||||||||
| Practice Location | |||||||||
| Address1: | 7300 CANTON CENTER DR | ||||||||
| Address2: | (EMERGENCY DEPT) | ||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481871579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344548002 | ||||||||
| FaxNumber: | 7344548161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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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 | 207P00000X | 5101011186 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11288428 | 01 | CAQH | OTHER |