1003818907 NPI number — DR. GEORGE DANIEL SHANAHAN IV DPM

Table of content: DR. BERT E TAGERT M.D. (NPI 1104828003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003818907 NPI number — DR. GEORGE DANIEL SHANAHAN IV DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANAHAN
Provider First Name:
GEORGE
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
IV
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003818907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9640 COMMERCE RD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COMMERCE TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48382-4167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-360-3888
Provider Business Mailing Address Fax Number:
248-363-0894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9640 COMMERCE RD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMERCE TWP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48382-4167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-360-3888
Provider Business Practice Location Address Fax Number:
248-363-0894
Provider Enumeration Date:
08/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  GDS001605 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38-3128264 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 130147 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: GDS001605 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5631126 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: U43179 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 297370213 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4778520001 . This is a "DME ADMINISTAR FEDERAL" identifier . This identifiers is of the category "OTHER".




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