MEDICARE: BRIDGEVIEW MEDICAL CLINIC, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1992734800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEVIEW MEDICAL CLINIC, PC

Provider Business Mailing Address
First Line	:	39833 BRIDGEVIEW ST
Second Line	:
City	:	HARRISON TOWNSHIP
State	:	MI
Zip	:	48045-1601
Country	:	US
Telephone Number	:	586-627-2727
Fax Number	:

Provider Business Practice Location Address
First Line	:	39833 BRIDGEVIEW ST
Second Line	:
City	:	HARRISON TOWNSHIP
State	:	MI
Zip	:	48045-1601
Country	:	US
Telephone Number	:	586-627-2727
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MARTHA J SHADEL
Credential	:	D.O.
Telephone Number	:	586-627-2727

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	08/22/2020

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