Healthcare Provider Details

I. General information

NPI: 1639097041
Provider Name (Legal Business Name): MID-MICHIGAN PEDIATRIC GASTROENTEROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W WACKERLY ST STE 9
MIDLAND MI
48640-2769
US

IV. Provider business mailing address

720 W WACKERLY ST STE 9
MIDLAND MI
48640-2769
US

V. Phone/Fax

Practice location:
  • Phone: 989-423-0607
  • Fax: 989-423-0608
Mailing address:
  • Phone: 989-423-0607
  • Fax: 989-423-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAMEL AMIN
Title or Position: OWNER
Credential: MD
Phone: 989-423-0607