1093889503 NPI number — POALA D. PRUDE-HALL M.D.

Table of content: POALA D. PRUDE-HALL M.D. (NPI 1093889503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093889503 NPI number — POALA D. PRUDE-HALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUDE-HALL
Provider First Name:
POALA
Provider Middle Name:
D.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093889503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 NORTH CLIPPERT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-333-9200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 N CLIPPERT ST
Provider Second Line Business Practice Location Address:
LANSING URGENT CARE
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48912-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-333-9200
Provider Business Practice Location Address Fax Number:
517-333-9201
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301058586 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PP058586 . This is a "CHAMPUS-CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: PP058586 . This is a "COMMERCIAL-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 327176910 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080H262390 . This is a "BLUE CROSS-BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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