Provider Demographics
NPI:1912989948
Name:SCIUCA, DAN S (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:S
Last Name:SCIUCA
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 1:1659 TRAIL RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4900
Mailing Address - Country:US
Mailing Address - Phone:269-998-5398
Mailing Address - Fax:269-341-7781
Practice Address - Street 1:1659 TRAIL RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-998-5398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078831207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4347244 10Medicaid
MI700G560080OtherBCBS GROUP
MI382317300 140OtherCOMM CHOICE MI-IM
MI382317300 154OtherCOMM CHOICE MI-TR
MI4601303 10Medicaid
MI143068OtherGREAT LAKES HEALTH PLAN-T
MI382317300 107OtherCOMM CHOICE MI-WP
MI4460009 10Medicaid
MI4848285Medicaid
MI1107500612OtherBCBS PIN
MI4938130 10Medicaid
MI0G56008OtherMEDICARE GROUP
MI143068OtherGREAT LAKES HEALTH PLAN-T
MI1107500612OtherBCBS PIN
MI382317300 140OtherCOMM CHOICE MI-IM