Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0103X | Foot & Ankle Surgery | GDS001605 | MI |
NPI | 1003818907 |
---|---|
Provider Name | Dr. George Daniel Shanahan IV |
First Address | Commerce Twp, MI 48382-4167 |
Second Address | Commerce Twp, MI 48382-4167 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2005 |
Last Update Date | 19/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
130147 | CARE CHOICES (01) | MI |
297370213 | (05) | MI |
38-3128264 | TAX ID (01) | |
4778520001 | DME ADMINISTAR FEDERAL (01) | |
5631126 | BLUE CROSS BLUE SHIELD (01) | MA |
GDS001605 | STATE LICENSE (01) | MI |
U43179 | (02) | |
U43179 | HAP (01) | MI |