Provider Demographics
NPI:1053394288
Name:GANETSKY, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GANETSKY
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 1:1 DEACONESS RD
Mailing Address - Street 2:WCC-2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5321
Mailing Address - Country:US
Mailing Address - Phone:617-754-2323
Mailing Address - Fax:617-754-2350
Practice Address - Street 1:1 DEACONESS RD # WCC-2
Practice Address - Street 2:BIDMC, DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5321
Practice Address - Country:US
Practice Address - Phone:617-754-2323
Practice Address - Fax:617-754-2350
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220259207P00000X, 207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2042011Medicaid
MAGA A36746Medicare ID - Type Unspecified
MAI06178Medicare UPIN