NPIMap

Individual provider Active NPI

Shana A Ageloff-Kupetz, MD

  • Family Medicine Physician
  • Jackson, MI
National Provider Identifier
1437385382
Registry record updated Jan 9, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
4301097152 Issued in MI
Practice address
3235 E Michigan Ave
Jackson, MI 49202-3971
Phone
(517) 787-3280
Fax
(517) 787-9680
NPI assigned
Jun 5, 2009
Last updated
Jan 9, 2014By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 9, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 4301097152 MI Primary

Addresses

Primary practice location

3235 E Michigan Ave
Jackson, MI 49202-3971

Mailing address

3235 E Michigan Ave
Jackson, MI 49202-3971
Phone (517) 787-3280

Other identifiers 9

IdentifierTypeStateIssuer
080G31660OtherMIBLUE CROSS BLUE SHIELD OF MICHIGAN
1437385382OtherMIMOLINA HEALTH PLAN OF MICHIGAN
1062975OtherMIMCLAREN HEALTH PLAN
381908328470OtherMICARE SOURCE OF MICHIGAN
185245OtherMIGREAT LAKES HREALTH PLAN OF MICHIGAN
381908328OtherMOHCAP
1437385382MedicaidMI
381908328OtherMIPRIORITY HEALTH
45592OtherCOSTATE LICENSE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20110111000754 MI Practitioner - Family Practice 9638200538 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Pennsylvania State University College of Medicine, 2006
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

3235 E Michigan Ave
100 Henry Ford Allegiance Family Medicine E
Jackson, MI 49202-3971
Phone (517) 205-3280

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
4301097152MIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
W.a. Foote Memorial Hospital, Inc CurrentSince Jan 7, 2013 Accepting new patients
W. a. Foote Memorial Hospital, Inc Current Accepting new patients
Henry Ford Pathology Current Accepting new patients
Wa Foote Memorial Hospital Inc Family Medicine CurrentSince Jan 7, 2013 Accepting new patients
Wa Foote Memorial Hospital, Inc Past Accepting new patients
Cogent Healthcare of Michigan PC Family Medicine Past Accepting new patients
Great Lakes Bay Health Centers Past Accepting new patients
Great Lakes Bay Health Centers Past Accepting new patients

Locations

205 N East Ave
Jackson, MI 49201
Phone (517) 788-4730

3235 E Michigan Ave
Jackson, MI 49202
Phone (517) 787-3280

3235 E Michigan Ave
Ste 100
Jackson, MI 49202
Phone (517) 205-3280

130 N Sherman St
Leslie, MI 49251
Phone (517) 205-2500

Interoperability endpoints

  • Direct secure messaging: sageloffkupetz452689@direct.hfhs.org

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1244160000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1389225600000",
    "number": "1437385382",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3235 E MICHIGAN AVE",
            "city": "JACKSON",
            "state": "MI",
            "postal_code": "492023971",
            "telephone_number": "517-787-3280",
            "fax_number": "517-787-9680"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3235 E MICHIGAN AVE",
            "city": "JACKSON",
            "state": "MI",
            "postal_code": "492023971",
            "telephone_number": "517-787-3280",
            "fax_number": "517-787-9680"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "AGELOFF-KUPETZ",
        "first_name": "SHANA",
        "middle_name": "A",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2009-06-05",
        "last_updated": "2014-01-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "4301097152",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD OF MICHIGAN",
            "identifier": "080G31660",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MOLINA HEALTH PLAN OF MICHIGAN",
            "identifier": "1437385382",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MCLAREN HEALTH PLAN",
            "identifier": "1062975",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CARE SOURCE OF MICHIGAN",
            "identifier": "381908328470",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GREAT LAKES HREALTH PLAN OF MICHIGAN",
            "identifier": "185245",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HCAP",
            "identifier": "381908328",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1437385382",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRIORITY HEALTH",
            "identifier": "381908328",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "45592",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jackson, MI

Sources for this page

Verify at the official NPI Registry.