Healthcare Provider Details

I. General information

NPI: 1265798813
Provider Name (Legal Business Name): TONY PURKAL RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 05/17/2025
Certification Date: 05/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

633 EMERSON ST
EVANSTON IL
60208-0844
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-0914
  • Fax:
Mailing address:
  • Phone: 847-491-2144
  • Fax: 847-467-6869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704419970
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303049912
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: