Healthcare Provider Details

I. General information

NPI: 1164710406
Provider Name (Legal Business Name): LORIEN PATRICE SHACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORIEN P SHACK MD

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR. SUITE 5011
YPSILANTI MI
48197
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR STE J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-8700
  • Fax: 734-622-5017
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number4301099212
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number4301099212
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301099212
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: