Basic Information
| Provider Information | |||||||||
| NPI: | 1881654887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEINER | ||||||||
| FirstName: | SHELDON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29992 NORTHWESTERN HWY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485512446 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3577 W 13 MILE RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485512441 | ||||||||
| FaxNumber: | 2485511094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 03/31/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 4301039690 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 700H273300 | 01 | MI | BLUE SHIELD GROUP | OTHER | 160F376970 | 01 | MI | BLUE SHIELD INDIVIDUAL | OTHER | 1881654887 | 05 | MI | MEDICAID |