Poala D. Prude-Hall, M.D. – Family Medicine Physician

Key facts

NPI: 1093889503
Entity type: Individual (NPI type 1)
Primary specialty: Family Medicine Physician 207Q00000X
License: 4301058586 (MI)
Practice address: 505 N Clippert St
Lansing Urgent Care
Lansing, MI 48912-4701
Phone: (517) 333-9200
Fax: (517) 333-9201
NPI assigned: Nov 17, 2006
Sex: Female
Sole proprietor: No

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Henry Ford Health System General Acute Care Hospital · Detroit, MI · NPI 1134144801

Medicare reassignment NPD MI
Ambulatory United Gynecology Physician · Greenville, MI · NPI 1104931492

NPD (past)
Lansing Urgent Care, PLC Urgent Care Clinic/Center · Lansing, MI · NPI 1780987990

NPD (past)

Medicare participation

Medicare fee-for-service enrollment: Enrolled in MI
Eligible to order & refer: Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
I20050304000728	MI	Practitioner - Family Practice	0547214215	Reassigns benefits to 1 organization

National Provider Directory

Medicare enrollment (NPD): Yes
Credentials: Doctor of Medicine

State licenses

License	State	Type	Specialty
4301058586	MI	MD	Family Medicine Physician

Practice roles

Organization	Status	New patients
Henry Ford Health System	Current	Accepting new patients
Lansing Urgent Care, PLC	Past	Accepting new patients
Ambulatory United	Past	Accepting new patients

Locations

2799 W Grand Blvd
Detroit, MI 48202
Phone (313) 876-2062

Interoperability endpoints

Direct secure messaging: pprudehall13003@direct.hfhs.org

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Family Medicine Physician	207Q00000X	4301058586	MI	Yes

Addresses

Primary practice location

505 N Clippert St
Lansing Urgent Care
Lansing, MI 48912-4701

Mailing address

505 North Clippert
Lansing, MI 48912
Phone (517) 333-9200

Other identifiers

Identifier	Type	State	Issuer
PP058586	Other		CHAMPUS-CHAMPUS
PP058586	Other		COMMERCIAL-COMMERCIAL NUMBER
327176910	Medicaid	MI
080H262390	Other		BLUE CROSS-BLUE CROSS

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Nov 15, 2013.

{
    "created_epoch": "1163721600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1384473600000",
    "number": "1093889503",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "505 NORTH CLIPPERT",
            "city": "LANSING",
            "state": "MI",
            "postal_code": "48912",
            "telephone_number": "517-333-9200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "505 N CLIPPERT ST",
            "address_2": "LANSING URGENT CARE",
            "city": "LANSING",
            "state": "MI",
            "postal_code": "489124701",
            "telephone_number": "517-333-9200",
            "fax_number": "517-333-9201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PRUDE-HALL",
        "first_name": "POALA",
        "middle_name": "D.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-11-17",
        "last_updated": "2013-11-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "4301058586",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CHAMPUS-CHAMPUS",
            "identifier": "PP058586",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "COMMERCIAL-COMMERCIAL NUMBER",
            "identifier": "PP058586",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "327176910",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS-BLUE CROSS",
            "identifier": "080H262390",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lansing, MI

All providers in Lansing, MI · Family Medicine Physician in Michigan

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 15, 2013. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
Order and Referring (CMS).
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.