Basic Information
| Provider Information | |||||||||
| NPI: | 1275574824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100 | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480680100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6245 INKSTER RD | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481354001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344583300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 06/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 5101013226 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 114454656 | 05 | MI | MEDICAID | 114703386 | 05 | MI | MEDICAID | KD013226 | 01 | MI | BC/BS OF MICHIGAN | OTHER | 114308362 | 05 | MI | MEDICAID | 114454665 | 05 | MI | MEDICAID |