=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992750681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHELLEY FREIMARK, MD, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 04/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11257 LAKESHORE DR
-----------------------------------------------------
City | GRAND HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49417-8825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-566-3379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11257 LAKESHORE DR
-----------------------------------------------------
City | GRAND HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49417-8825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHELLEY LYNN FREIMARK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 616-296-1143
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 4301066173
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------