1588755714 NPI number — MANOO BOONSIRI,M.D.,P.C.

Table of content: (NPI 1588755714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588755714 NPI number — MANOO BOONSIRI,M.D.,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANOO BOONSIRI,M.D.,P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

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 Information

NPI Number:
1588755714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
730 N MACOMB ST
Provider Second Line Business Mailing Address:
SUITE 415
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48162-2900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-243-5822
Provider Business Mailing Address Fax Number:
734-241-3350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10501 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
TAYLOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48180-3375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-295-7822
Provider Business Practice Location Address Fax Number:
734-241-3350
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOONSIRI
Authorized Official First Name:
MANOO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
734-243-5822

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  35446 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1798170 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3305801051 . This is a "BLUECROSS BLUESHIELD MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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