Provider Demographics
NPI:1922106103
Name:ERIC STOCKALL, MD, PLLC
Entity Type:Organization
Organization Name:ERIC STOCKALL, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STOCKALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-349-3900
Mailing Address - Street 1:PO BOX 1070
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48805-1070
Mailing Address - Country:US
Mailing Address - Phone:517-349-3900
Mailing Address - Fax:
Practice Address - Street 1:2090 JOLLY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3996
Practice Address - Country:US
Practice Address - Phone:517-349-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050188208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P02760Medicare PIN