Provider Demographics
NPI:1700950219
Name:GEORGE, DIANE L (DO)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:GEORGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:14500 HALL ROAD
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313
Mailing Address - Country:US
Mailing Address - Phone:586-247-2700
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:14500 HALL ROAD
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313
Practice Address - Country:US
Practice Address - Phone:586-247-2700
Practice Address - Fax:586-247-2691
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101010642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DS010642OtherCOMMERCIAL-COMMERCIAL NUMBER
080H262390OtherBLUE CROSS-BLUE CROSS
DS010642OtherCHAMPUS-CHAMPUS
MI326226911Medicaid
DS010642OtherCOMMERCIAL-COMMERCIAL NUMBER
MI326226911Medicaid