Healthcare Provider Details

I. General information

NPI: 1538886221
Provider Name (Legal Business Name): DANE MCNELIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N TELEGRAPH RD
PONTIAC MI
48341-1032
US

IV. Provider business mailing address

39314 WANDA AVE
STERLING HEIGHTS MI
48313-5569
US

V. Phone/Fax

Practice location:
  • Phone: 800-231-1127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number2000774
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: