Prosperity Medical, PLLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

PROSPERITY MEDICAL, PLLC

Doing business as

Stonegate Dermatology and Medical Spa

Practice address

3901 Stonegate Park Ste 300
Saint Joseph, MI 49085-9136

Phone

(269) 408-4265

Fax

(269) 556-6020

NPI assigned

Dec 22, 2023

Organization subpart

Yes

Parent organization

PROSPERITY MEDICAL, PLLCAs reported in NPPES

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

Authorized official

Name

Dr. Riddhi Jay Shah, DONPI 1568504397

Title

Physician

Phone

(516) 263-0167

Specialties & licenses 1

Addresses

Other names 1

• Stonegate Dermatology and Medical Spa Doing business as

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

Part of

Prosperity Medical PLLC

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

• Prosperity Medical, LLC

  • Home Health Agency
  • Plymouth, MI
  • NPI 1356132914
  NPPES parent name

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Riddhi Jay Shah, D.O.

  • Dermatology Physician
  • Saint Joseph, MI
  • NPI 1568504397
  Medicare reassignment Care Compare group NPD Authorized official
• Kaylee Diekevers, PA-C

  • Dermatology Physician
  • Grand Rapids, MI
  • NPI 1346938115
  Medicare reassignment Care Compare group
• Samuel Ernest Logan, M.D., PHD

  • Plastic Surgery Physician
  • Saint Joseph, MI
  • NPI 1013914241
  NPD (past)

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

{
    "created_epoch": "1703203200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1703203200000",
    "number": "1528837218",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 546",
            "city": "STEVENSVILLE",
            "state": "MI",
            "postal_code": "491270546",
            "telephone_number": "516-263-0167"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3901 STONEGATE PARK STE 300",
            "city": "SAINT JOSEPH",
            "state": "MI",
            "postal_code": "490859136",
            "telephone_number": "269-408-4265",
            "fax_number": "269-556-6020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROSPERITY MEDICAL, PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROSPERITY MEDICAL, PLLC",
        "enumeration_date": "2023-12-22",
        "last_updated": "2023-12-22",
        "certification_date": "2023-12-22",
        "status": "A",
        "authorized_official_last_name": "SHAH",
        "authorized_official_first_name": "RIDDHI",
        "authorized_official_middle_name": "JAY",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "516-263-0167",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Stonegate Dermatology and Medical Spa",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Dermatology Physician in Saint Joseph, MI
• Providers in Saint Joseph, MI by specialty
• Dermatology Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.