Healthcare Provider Details

I. General information

NPI: 1477603587
Provider Name (Legal Business Name): MORRIS E. GALES III MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date: 11/11/2008
Reactivation Date: 02/26/2014

III. Provider practice location address

29556 SOUTHFIELD RD SUITE 200
SOUTHFIELD MI
48076-2021
US

IV. Provider business mailing address

29556 SOUTHFIELD RD SUITE 200
SOUTHFIELD MI
48076-2021
US

V. Phone/Fax

Practice location:
  • Phone: 248-423-1550
  • Fax: 248-423-1552
Mailing address:
  • Phone: 248-423-1550
  • Fax: 248-423-1552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301049444
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704114991
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704207635
License Number StateMI

VIII. Authorized Official

Name: DR. MORRIS EDWARD GALES III
Title or Position: PRESIDENT
Credential: MD,FCCWS
Phone: 248-423-1550