Basic Information
| Provider Information | |||||||||
| NPI: | 1154394674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18900 W 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480752669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484248340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18900 W TEN MILE ROAD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480752669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484248340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | GD022523 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GD022523 | 01 | MI | BLUE CROSS LICENSE # | OTHER | 104787949 | 05 | MI | MEDICAID |