Healthcare Provider Details

I. General information

NPI: 1649596800
Provider Name (Legal Business Name): JEFFREY MORRIS HOTALING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26400 W 12 MILE RD STE 111
SOUTHFIELD MI
48034-1771
US

IV. Provider business mailing address

1560 E MAPLE RD STE 400 - CREDENTIALING DEPT
TROY MI
48083-1135
US

V. Phone/Fax

Practice location:
  • Phone: 248-357-4151
  • Fax: 248-357-0229
Mailing address:
  • Phone: 248-581-5973
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301113636
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD454807
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number303189
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: