Healthcare Provider Details

I. General information

NPI: 1538689740
Provider Name (Legal Business Name): SHIVA SHROTRIYA MD, LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 FOREST RD
LANSING MI
48910-3720
US

IV. Provider business mailing address

804 SERVICE RD STE A202
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-975-9500
  • Fax: 517-975-9520
Mailing address:
  • Phone: 517-975-9500
  • Fax: 517-975-9520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301502250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: