Provider Demographics
NPI:1003818907
Name:SHANAHAN, GEORGE DANIEL IV (DPM)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DANIEL
Last Name:SHANAHAN
Suffix:IV
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9640 COMMERCE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4167
Mailing Address - Country:US
Mailing Address - Phone:248-360-3888
Mailing Address - Fax:248-363-0894
Practice Address - Street 1:9640 COMMERCE RD STE 102
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382-4167
Practice Address - Country:US
Practice Address - Phone:248-360-3888
Practice Address - Fax:248-363-0894
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGDS001605213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
38-3128264OtherTAX ID
MI130147OtherCARE CHOICES
MIGDS001605OtherSTATE LICENSE
MA5631126OtherBLUE CROSS BLUE SHIELD
MIU43179OtherHAP
MI297370213Medicaid
4778520001OtherDME ADMINISTAR FEDERAL
MIU43179OtherHAP
MI297370213Medicaid