Healthcare Provider Details

I. General information

NPI: 1235110289
Provider Name (Legal Business Name): SHORES DIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29230 RYAN RD STE C-1
WARREN MI
48092-4274
US

IV. Provider business mailing address

29230 RYAN RD STE C-1
WARREN MI
48092-4274
US

V. Phone/Fax

Practice location:
  • Phone: 313-285-8728
  • Fax: 313-784-9055
Mailing address:
  • Phone: 313-285-8728
  • Fax: 313-784-9055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GULAM MOHIUDDIN
Title or Position: PRESIDENT
Credential:
Phone: 313-285-8728