Provider Demographics
NPI:1154495661
Name:KROLL, HENRY R (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:R
Last Name:KROLL
Suffix:
Gender:M
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BOULEVARD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2436
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BOULEVARD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI407431208VP0000X
MI4301407431207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HK407431OtherCHAMPUS-CHAMPUS
MI410070110Medicaid
700H262180OtherBLUE CROSS-BLUE CROSS
HK407431OtherCOMMERCIAL-COMMERCIAL NUMBER
HK407431OtherCOMMERCIAL-COMMERCIAL NUMBER
F07602Medicare UPIN