MEDICARE: MICHAEL DUBOSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	104100000X	Social Worker	6801099305	MI

General Provider Information

NPI Number	:	1265977128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL DUBOSE

Provider Business Mailing Address
First Line	:	5725 NEWBERRY DR
Second Line	:	APT 201
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-7434
Country	:	US
Telephone Number	:	313-918-8304
Fax Number	:

Provider Business Practice Location Address
First Line	:	5725 NEWBERRY DR
Second Line	:	APT 201
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-7434
Country	:	US
Telephone Number	:	313-918-8304
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2017
Last Update Date	:	01/03/2017

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