Healthcare Provider Details

I. General information

NPI: 1649709502
Provider Name (Legal Business Name): SHINING SHIELD MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

15140 16TH AVE
MARNE MI
49435-9605
US

IV. Provider business mailing address

207 CAPITAL AVE NE
BATTLE CREEK MI
49017-3926
US

V. Phone/Fax

Practice location:
  • Phone: 269-704-7563
  • Fax:
Mailing address:
  • Phone: 269-266-2863
  • Fax: 269-964-5740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY JANAS
Title or Position: PRESIDENT
Credential: MD
Phone: 269-589-1056