Healthcare Provider Details

I. General information

NPI: 1891919312
Provider Name (Legal Business Name): SHADI IDRIS MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 SHAFFER ST SUITE 002
KALAMAZOO MI
49048-1623
US

IV. Provider business mailing address

1717 SHAFFER ST SUITE 002
KALAMAZOO MI
49048-1623
US

V. Phone/Fax

Practice location:
  • Phone: 269-552-2823
  • Fax: 269-552-2964
Mailing address:
  • Phone: 269-552-2823
  • Fax: 269-552-2964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number54455
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301085994
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number54455
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number4301085994
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: