Healthcare Provider Details

I. General information

NPI: 1235875642
Provider Name (Legal Business Name): JACOB CARL HAGUE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

7934 N SHORE CT
GRAWN MI
49637-9581
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-1000
  • Fax:
Mailing address:
  • Phone: 248-534-2819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberV9616
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101028922
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: