Provider Demographics
NPI:1215962345
Name:SHIRLEY T SHERROD MD PC
Entity type:Organization
Organization Name:SHIRLEY T SHERROD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHERROD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-320-7200
Mailing Address - Street 1:22200 W 11 MILE RD
Mailing Address - Street 2:BOX NO. 515
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-7136
Mailing Address - Country:US
Mailing Address - Phone:313-320-7200
Mailing Address - Fax:
Practice Address - Street 1:22200 W 11 MILE RD
Practice Address - Street 2:BOX NO. 515
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48037-7136
Practice Address - Country:US
Practice Address - Phone:313-320-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033837207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1097952 10Medicaid
MI48818OtherOMNICARE COVENTRY PIN
MIB43583OtherHEALTH ALLIANCE PLAN PIN
MI1213150005OtherWELLNESS PLAN PIN
MI122752OtherGREAT LAKES HEALTH PLAN PIN
MI1808205381OtherBLUE CROSS BLUE SHIELD
MI5536239OtherAETNA PIN
MI1213150005OtherWELLNESS PLAN PIN
MI48818OtherOMNICARE COVENTRY PIN