Provider Demographics
NPI:1366238818
Name:TRIPP, SHANE (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:TRIPP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E HOSPITAL DR.
Mailing Address - Street 2:D3230
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109
Mailing Address - Country:US
Mailing Address - Phone:734-647-1774
Mailing Address - Fax:
Practice Address - Street 1:3399 E GRAND RIVER AVE STE 202
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-7555
Practice Address - Country:US
Practice Address - Phone:734-539-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351053872390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program