Provider Demographics
NPI:1326481623
Name:MICHIGAN SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:MICHIGAN SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:HADLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-562-4700
Mailing Address - Street 1:23902 FORD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3246
Mailing Address - Country:US
Mailing Address - Phone:313-562-4700
Mailing Address - Fax:313-562-4701
Practice Address - Street 1:23902 FORD RD
Practice Address - Street 2:SUITE A
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3246
Practice Address - Country:US
Practice Address - Phone:313-562-4700
Practice Address - Fax:313-562-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065806207QS0010X
MI4301095806332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H28306OtherBCBS GRP
MIDU1788OtherRAILROAD MEDICARE
MI0H28306OtherBCN GRP
MI1326481623Medicaid
MI6986550001OtherMEDICARE DME
MI0H28306OtherBCBS GRP