=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326481623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHIGAN SPORTS MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2013
-----------------------------------------------------
Last Update Date | 05/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23902 FORD RD SUITE A
-----------------------------------------------------
City | DEARBORN HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48127-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-562-4700
-----------------------------------------------------
Fax | 313-562-4701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23902 FORD RD SUITE A
-----------------------------------------------------
City | DEARBORN HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48127-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-562-4700
-----------------------------------------------------
Fax | 313-562-4701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. TAREK HADLA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-562-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 4301095806
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 4301065806
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------