Healthcare Provider Details

I. General information

NPI: 1972851608
Provider Name (Legal Business Name): FAMILY GASTROENTEROLOGY P L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 W CEDAR ST
STANDISH MI
48658-9526
US

IV. Provider business mailing address

PO BOX 125
STANDISH MI
48658-0125
US

V. Phone/Fax

Practice location:
  • Phone: 989-846-3555
  • Fax: 989-846-3462
Mailing address:
  • Phone: 989-846-3500
  • Fax: 989-846-3462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301064684
License Number StateMI

VIII. Authorized Official

Name: DR. IBRAHIM S SHAMIEH
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 989-846-3500