=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366240236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IEP MCO ORTHOPEDIC URGENT CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2025
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6405 TELEGRAPH RD
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48301-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-997-4690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37000 GRAND RIVER AVE STE 310
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48335-2868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-536-2127
-----------------------------------------------------
Fax | 248-893-6952
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DAVID GERALD HALL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-536-2127
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------