Healthcare Provider Details

I. General information

NPI: 1326481623
Provider Name (Legal Business Name): MICHIGAN SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23902 FORD RD SUITE A
DEARBORN HEIGHTS MI
48127-3246
US

IV. Provider business mailing address

23902 FORD RD SUITE A
DEARBORN HEIGHTS MI
48127-3246
US

V. Phone/Fax

Practice location:
  • Phone: 313-562-4700
  • Fax: 313-562-4701
Mailing address:
  • Phone: 313-562-4700
  • Fax: 313-562-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301065806
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4301095806
License Number StateMI

VIII. Authorized Official

Name: DR. TAREK HADLA
Title or Position: MD
Credential: MD
Phone: 313-562-4700