Provider Demographics
NPI:1154582112
Name:HALL, MISS WEDNESDAY (DO)
Entity type:Individual
Prefix:DR
First Name:MISS
Middle Name:WEDNESDAY
Last Name:HALL
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11012 E 13 MILE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2546
Mailing Address - Country:US
Mailing Address - Phone:586-459-5592
Mailing Address - Fax:
Practice Address - Street 1:32300 NORTHWESTERN HWY STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1501
Practice Address - Country:US
Practice Address - Phone:248-574-9534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101020142208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E06376OtherBCBSM
MI381958736Medicaid