Provider Demographics
NPI:1407830490
Name:DANIELSKY, HENRY GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:GEORGE
Last Name:DANIELSKY
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1202 W OAK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2155
Practice Address - Country:US
Practice Address - Phone:616-754-4685
Practice Address - Fax:616-754-9883
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHD049246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1866430Medicaid
MI0805930152OtherBCBSMI
MI1866430Medicaid
MIB47504Medicare UPIN