Healthcare Provider Details

I. General information

NPI: 1730471368
Provider Name (Legal Business Name): JUSTIN L SHIELDS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE STE 5100
GRAND RAPIDS MI
49503-2572
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC-845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-0800
  • Fax: 616-267-0801
Mailing address:
  • Phone: 616-267-0800
  • Fax: 616-267-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006017
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: