Provider Demographics
NPI:1053417816
Name:G. DANIEL SHANAHAN IV DPM PC
Entity type:Organization
Organization Name:G. DANIEL SHANAHAN IV DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:IV
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-360-3888
Mailing Address - Street 1:9640 COMMERCE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4167
Mailing Address - Country:US
Mailing Address - Phone:248-360-3888
Mailing Address - Fax:248-363-0894
Practice Address - Street 1:9640 COMMERCE RD STE 102
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382-4167
Practice Address - Country:US
Practice Address - Phone:248-360-3888
Practice Address - Fax:248-363-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770712358OtherJENNIFER L PETRONELLA DPM NPI NUMBER
MI5901002333OtherJENNIFER L PETRONELLA DPM STATE LICENSE
MI5901001605OtherG DANIEL SHANAHAN IV DPM STATE LICENSE
N78970OtherMEDICARE GROUP NUMBER
MI480F321940OtherBLUE CROSS BLUE SHIELD
1003818907OtherG. D SHANAHAN DPM NPI #
1790880284OtherAIMEE A. POPOFSKI DPM NPI NUMBER
MI5901002236OtherAIMEE A. POPOFSKI STATE LICENSE
MI480F321940OtherBLUE CROSS BLUE SHIELD
1003818907OtherG. D SHANAHAN DPM NPI #
N78970OtherMEDICARE GROUP NUMBER