SHELBYDALE MEDICAL CLINIC, P.C.
NPI 1629258488
Family Medicine in Shelby Twp, MI
About Shelbydale Medical Clinic, P.c. NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
SHELBYDALE MEDICAL CLINIC, P.C. (NPI 1629258488) is a healthcare organization registered as a family medicine in Shelby Twp, Michigan and active in the NPI registry since November 2007. The organization holds a CLIA Microscopy certificate valid through June 8, 2028 and lists Keith B Tom, President, as its authorized official.
NPPES Registry Identity
Specialties & Licenses
Other Identifiers 3
Group Practice 1
Accepted Insurance
Medicare Participation & PECOS CMS
Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
Shelbydale Medical Clinic, P.c. is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Clinicians Billing Medicare Through This Organization
Medicare enrollment records show 1 clinician reassigns Medicare billing to Shelbydale Medical Clinic, P.C., which bills Medicare for the services this clinician delivers.
Clinician (1)
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
CLIA Laboratory Certificates CMS CLIA
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate for Provider-Performed Microscopy Procedures (PPMP) 23D0868870
Shelbydale Medical Clinic PC · Shelby Township, MIFrequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Shelbydale Medical Clinic, P.C.'s NPI number?
The NPI number for Shelbydale Medical Clinic, P.C. is 1629258488. It was assigned to this organization in the NPPES registry on November 9, 2007.
Where is Shelbydale Medical Clinic, P.C. located?
Shelbydale Medical Clinic, P.C. is located at 49221 Van Dyke Ave, Shelby Twp, MI 48317. The listed phone number is (586) 254-4860.
What is Shelbydale Medical Clinic, P.C.'s specialty?
The primary specialty registered for this NPI is Family Medicine with taxonomy code 207Q00000X.
Is Shelbydale Medical Clinic, P.C. enrolled in Medicare?
Yes. Shelbydale Medical Clinic, P.C. is registered in the Medicare PECOS enrollment system.
How many clinicians bill Medicare through Shelbydale Medical Clinic, P.C.?
According to the CMS Revalidation Reassignment List (October 2026 release), 1 clinician (Family Practice) reassigns their Medicare billing to Shelbydale Medical Clinic, P.C.. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Does Shelbydale Medical Clinic, P.C. hold a CLIA laboratory certificate?
Yes. A Certificate for Provider-Performed Microscopy Procedures (PPMP) (number 23D0868870) is associated with this NPI, valid through June 8, 2028. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.
What insurance does Shelbydale Medical Clinic, P.C. accept?
Health plans from Blue Cross Blue Shield of Michigan Mutual Insurance Company list Shelbydale Medical Clinic, P.C. as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.
When was this NPI record last updated?
The NPPES record for Shelbydale Medical Clinic, P.C. was last updated on November 9, 2007. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 18 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Shelbydale Medical Clinic, P.c. · NPI 1629258488
Family Medicine organization in Shelby Twp, Michigan. Organization record, active in the CMS NPPES registry since November 9, 2007.
## Identity
- **NPI:** 1629258488 (Entity type: Organization)
- **Enumerated:** November 9, 2007
- **Primary specialty:** Family Medicine · taxonomy 207Q00000X
- **Organization subpart:** No
- **Authorized official:** Keith Tom, PRESIDENT
## Practice location
- **Address:** 49221 VAN DYKE AVE, Shelby Twp, MI 48317-1336
- **Phone:** (586) 254-4860 · **Fax:** (586) 254-5844
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Clinicians billing through this organization:** 1 clinician (Family Practice) reassigns Medicare billing to this organization (form CMS-855R) · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** November 9, 2007
- **Other identifiers:** Medicaid 2646558 (MI); Medicare PIN 0P04980; Medicare UPIN A77750
- **CLIA laboratory certificates:** 1 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1629258488) · Data from the CMS NPPES public registry.