Healthcare Provider Details

I. General information

NPI: 1558781500
Provider Name (Legal Business Name): CONRAD HILTON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 W OUTER DR
DETROIT MI
48235-2624
US

IV. Provider business mailing address

5660 INKSTER RD
WEST BLOOMFIELD MI
48323-3831
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-1020
  • Fax: 313-966-1024
Mailing address:
  • Phone: 406-925-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR1385
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: