Healthcare Provider Details

I. General information

NPI: 1073976213
Provider Name (Legal Business Name): REBECCA BOSTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W BIG BEAVER RD STE 100
BLOOMFIELD HILLS MI
48304-3913
US

IV. Provider business mailing address

60 W BIG BEAVER RD STE 100
BLOOMFIELD HILLS MI
48304-3913
US

V. Phone/Fax

Practice location:
  • Phone: 248-258-5100
  • Fax:
Mailing address:
  • Phone: 248-258-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number4301508638
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: