Provider Demographics
NPI:1003840422
Name:KANIEFSKI, WALTER J (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:KANIEFSKI
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 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING/PAYER CONTRACTING DEPT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-805-0477
Mailing Address - Fax:866-250-6385
Practice Address - Street 1:601 PARK ST
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1445
Practice Address - Country:US
Practice Address - Phone:570-253-8140
Practice Address - Fax:570-253-8633
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055974207P00000X
PAMD444759207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10394151OtherCAQH
PAPENDINGMedicaid
VA010295564Medicaid