Shelbydale Medical Clinic, P.C.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

KT008999 Issued in MI

Legal business name

SHELBYDALE MEDICAL CLINIC, P.C.

Practice address

49221 Van Dyke Ave
Shelby TWP, MI 48317-1336

Phone

(586) 254-4860

Fax

(586) 254-5844

NPI assigned

Nov 9, 2007

Organization subpart

No

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

Authorized official

Name

Keith B Tom, D.O.NPI 1609850130

Title

President

Phone

(586) 254-4860

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 1

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

• Keith B Tom, DO

  • Family Medicine Physician
  • Shelby TWP, MI
  • NPI 1609850130
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1194566400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1194566400000",
    "number": "1629258488",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "49221 VAN DYKE AVE",
            "city": "SHELBY TWP",
            "state": "MI",
            "postal_code": "483171336",
            "telephone_number": "586-254-4860",
            "fax_number": "586-254-5844"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "49221 VAN DYKE AVE",
            "city": "SHELBY TWP",
            "state": "MI",
            "postal_code": "483171336",
            "telephone_number": "586-254-4860",
            "fax_number": "586-254-5844"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHELBYDALE MEDICAL CLINIC, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-09",
        "last_updated": "2007-11-09",
        "status": "A",
        "authorized_official_last_name": "TOM",
        "authorized_official_first_name": "KEITH",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "586-254-4860",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "KT008999",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2646558",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Katelyn Marie Shaw
• Shelby Dental Center P.C.
• Shelby Urgent Care PC
• Shelby Urgent Care PC
• Shelby Urgent Care Walk-in Clinic
• Jason P Sheppard, LMSW- CLINICAL
• Linda Shkreli-Mosed, LMSW, LCSW, QMHP
• Yana Sifford, CNS
• Hailey Silk
• Andrew J Singles

• Family Medicine Physician in Shelby TWP, MI
• Providers in Shelby TWP, MI by specialty
• Family Medicine Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.