Provider Demographics
NPI:1497809859
Name:YANISH, GREGORY J (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:YANISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12499 UNIVERSITY AVE
Mailing Address - Street 2:STE. 210
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8288
Mailing Address - Country:US
Mailing Address - Phone:515-440-2676
Mailing Address - Fax:515-440-2677
Practice Address - Street 1:12499 UNIVERSITY AVE
Practice Address - Street 2:STE. 210
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8288
Practice Address - Country:US
Practice Address - Phone:515-440-2676
Practice Address - Fax:515-440-2677
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2013-01-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5315021056208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4982685Medicaid
MI0P40740Medicare PIN
MI4982685Medicaid