Provider Demographics
NPI:1124120423
Name:PERNELL, HESTER SUSIE (MD)
Entity type:Individual
Prefix:DR
First Name:HESTER
Middle Name:SUSIE
Last Name:PERNELL
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 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:313-794-5111
Mailing Address - Fax:
Practice Address - Street 1:20001 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3403
Practice Address - Country:US
Practice Address - Phone:313-794-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041286207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301041286OtherSTATE ID NUMBER
MI0630523Medicare ID - Type UnspecifiedID NUMBER
MIB44397Medicare UPIN