Provider Demographics
NPI:1093889503
Name:PRUDE-HALL, POALA D (MD)
Entity Type:Individual
Prefix:
First Name:POALA
Middle Name:D
Last Name:PRUDE-HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 NORTH CLIPPERT
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912
Mailing Address - Country:US
Mailing Address - Phone:517-333-9200
Mailing Address - Fax:
Practice Address - Street 1:505 N CLIPPERT ST
Practice Address - Street 2:LANSING URGENT CARE
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4701
Practice Address - Country:US
Practice Address - Phone:517-333-9200
Practice Address - Fax:517-333-9201
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PP058586OtherCHAMPUS-CHAMPUS
PP058586OtherCOMMERCIAL-COMMERCIAL NUMBER
MI327176910Medicaid
080H262390OtherBLUE CROSS-BLUE CROSS
080H262390OtherBLUE CROSS-BLUE CROSS
PP058586OtherCHAMPUS-CHAMPUS