1255310694 NPI number — DAVID J BOES DO

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255310694 NPI number — DAVID J BOES DO

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BOES

Provider First Name:

DAVID

Provider Middle Name:

J

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DO

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1255310694

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/29/2016

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

804 SERVICE RD

Provider Second Line Business Mailing Address:

# A201

Provider Business Mailing Address City Name:

EAST LANSING

Provider Business Mailing Address State Name:

MI

Provider Business Mailing Address Postal Code:

48824-7015

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

517-884-2976

Provider Business Mailing Address Fax Number:

517-432-3928

Provider First Line Business Practice Location Address:

2727 S PENNSYLVANIA AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

LANSING

Provider Business Practice Location Address State Name:

MI

Provider Business Practice Location Address Postal Code:

48910-3488

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

517-975-3750

Provider Business Practice Location Address Fax Number:

517-975-3755

Provider Enumeration Date:

01/13/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207V00000X , with the licence number:  5101007502 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1255310694 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: HEALTH ADVANTAGE . This is a "252502" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 252502 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 4308424 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 160C311260 . This is a "BLUE CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 160C311260 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 0700185 . This is a "PHYSICIANS HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 160C311260 . This is a "COMMUNITY BLUE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: F04444 . This is a "HEALTH NET FEDERAL SERVIC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 160C311260 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 4053266 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".