Provider Demographics
NPI:1144267758
Name:SHAW, NEIL T (DPM)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:T
Last Name:SHAW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27593 HARPER
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081
Mailing Address - Country:US
Mailing Address - Phone:586-779-6140
Mailing Address - Fax:586-779-9865
Practice Address - Street 1:27593 HARPER
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081
Practice Address - Country:US
Practice Address - Phone:586-779-6140
Practice Address - Fax:586-779-9865
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001895213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4532888Medicaid
MI4855010390OtherBLUE CROOS PIN NUMBER
MI4532888Medicaid
0M71310005Medicare PIN
MI4855010390OtherBLUE CROOS PIN NUMBER