Basic Information
| Provider Information | |||||||||
| NPI: | 1972851608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY GASTROENTEROLOGY P L L C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 125 | ||||||||
| Address2: | |||||||||
| City: | STANDISH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486580125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898463500 | ||||||||
| FaxNumber: | 9898463462 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 W CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | STANDISH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486589526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898463555 | ||||||||
| FaxNumber: | 9898463462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHAMIEH | ||||||||
| AuthorizedOfficialFirstName: | IBRAHIM | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9898463500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 4301064684 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0067065 | 01 | MI | BLUE CARE NETWORK | OTHER | 3500670651 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER | 1629026463 | 01 | MI | INDIVIDUAL NPI | OTHER | 0988839 | 01 | MI | HEALTH PLUS OF MICHIGAN | OTHER | 4255957 | 05 | MI | MEDICAID |