Provider Demographics
NPI:1386101293
Name:HALO PRIMARY CARE
Entity type:Organization
Organization Name:HALO PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANADY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEYDOUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-993-7777
Mailing Address - Street 1:22720 MICHIGAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2021
Mailing Address - Country:US
Mailing Address - Phone:313-891-2740
Mailing Address - Fax:
Practice Address - Street 1:1535 E STATE FAIR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1257
Practice Address - Country:US
Practice Address - Phone:313-891-2740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HALO MEDICAL GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-27
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14264493OtherCAQH
12715957OtherCAQH
MI1417245721Medicaid