Provider Demographics
NPI:1306952767
Name:GINNEBAUGH, DAVID ALAN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
Last Name:GINNEBAUGH
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 1:338 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3418
Mailing Address - Country:US
Mailing Address - Phone:313-886-0214
Mailing Address - Fax:
Practice Address - Street 1:43201 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1110
Practice Address - Country:US
Practice Address - Phone:586-228-0780
Practice Address - Fax:586-228-1809
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2756630Medicaid
A74155Medicare UPIN
MI0E06329Medicare PIN