Healthcare Provider Details

I. General information

NPI: 1972032027
Provider Name (Legal Business Name): JOHN HIPOL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2017
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22401 FOSTER WINTER DR
SOUTHFIELD MI
48075-3724
US

IV. Provider business mailing address

30160 MANOR DR
MADISON HEIGHTS MI
48071-2294
US

V. Phone/Fax

Practice location:
  • Phone: 248-561-3095
  • Fax:
Mailing address:
  • Phone: 248-561-3095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704295301
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11000298
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: