Healthcare Provider Details

I. General information

NPI: 1528368651
Provider Name (Legal Business Name): NOEL UPFALL D.O. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 EAST STATE FAIR
DETROIT MI
48203
US

IV. Provider business mailing address

1535 EAST STATE FAIR
DETROIT MI
48203
US

V. Phone/Fax

Practice location:
  • Phone: 313-891-2740
  • Fax: 313-891-0775
Mailing address:
  • Phone: 313-891-2740
  • Fax: 313-891-0775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: NOEL UPFALL
Title or Position: PRESIDENT
Credential: D.O.
Phone: 313-891-2740