Provider Demographics
NPI:1073559415
Name:DRAKE, GEORGE ERVING (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ERVING
Last Name:DRAKE
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 1:68449 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9504
Mailing Address - Country:US
Mailing Address - Phone:269-699-5776
Mailing Address - Fax:
Practice Address - Street 1:68449 SCOTT ST
Practice Address - Street 2:
Practice Address - City:EDWARDSBURG
Practice Address - State:MI
Practice Address - Zip Code:49112-9504
Practice Address - Country:US
Practice Address - Phone:269-699-5776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00218423OtherRR MEDICARE
MI4731175Medicaid
0801110581OtherBCBS
P17100001Medicare ID - Type Unspecified
A03288Medicare UPIN