Healthcare Provider Details

I. General information

NPI: 1609140029
Provider Name (Legal Business Name): SUPRIYA SHORE M.B.B.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 CHALLIS RD 2ND FLOOR
BRIGHTON MI
48116-9416
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 810-263-4000
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52579
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301114850
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301114850
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number4301114850
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: