Healthcare Provider Details

I. General information

NPI: 1144313107
Provider Name (Legal Business Name): CHERYL HOPE HACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30301 WOODWARD AVE SUITE LL 165
ROYAL OAK MI
48073-0979
US

IV. Provider business mailing address

25219 W ROYCOURT
HUNTINGTON WOODS MI
48070-1741
US

V. Phone/Fax

Practice location:
  • Phone: 248-435-9240
  • Fax: 248-435-4765
Mailing address:
  • Phone: 248-542-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number4301049051
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: