Healthcare Provider Details

I. General information

NPI: 1093799702
Provider Name (Legal Business Name): STEPHEN EARL BOODIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 W MAPLE RD SUITE 104
CLAWSON MI
48017-1000
US

IV. Provider business mailing address

909 W MAPLE RD SUITE 104
CLAWSON MI
48017-1000
US

V. Phone/Fax

Practice location:
  • Phone: 248-288-3200
  • Fax: 248-288-0530
Mailing address:
  • Phone: 248-288-3200
  • Fax: 248-288-0530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number032164
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: