Healthcare Provider Details

I. General information

NPI: 1235184037
Provider Name (Legal Business Name): SHEPHERD CLINIC PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W WRIGHT AVE
SHEPHERD MI
48883-2502
US

IV. Provider business mailing address

217 W WRIGHT AVE
SHEPHERD MI
48883-2502
US

V. Phone/Fax

Practice location:
  • Phone: 989-828-6691
  • Fax:
Mailing address:
  • Phone: 989-828-6691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101008087
License Number StateMI

VIII. Authorized Official

Name: KURT ANDERSON
Title or Position: OWNER
Credential: DO
Phone: 989-828-6691