Healthcare Provider Details

I. General information

NPI: 1003818907
Provider Name (Legal Business Name): GEORGE DANIEL SHANAHAN IV DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 COMMERCE RD STE 102
COMMERCE TWP MI
48382-4167
US

IV. Provider business mailing address

9640 COMMERCE RD STE 102
COMMERCE TWP MI
48382-4167
US

V. Phone/Fax

Practice location:
  • Phone: 248-360-3888
  • Fax: 248-363-0894
Mailing address:
  • Phone: 248-360-3888
  • Fax: 248-363-0894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberGDS001605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: