1891887675 NPI number — ROBERT I BOORSTEIN DO PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891887675 NPI number — ROBERT I BOORSTEIN DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT I BOORSTEIN DO PC
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:
ADVANCE SURGICAL ASSOCIAT
Provider Other Organization Name Type Code:
3
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:
1891887675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25500 MEADOWBROOK RD
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48375-1878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-478-7733
Provider Business Mailing Address Fax Number:
248-478-3533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25500 MEADOWBROOK RD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48375-1878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-478-7733
Provider Business Practice Location Address Fax Number:
248-478-3533
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOORSTEIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-478-7733

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  RB007073 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: MR011373 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1767737 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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