Healthcare Provider Details

I. General information

NPI: 1639610223
Provider Name (Legal Business Name): MARSHALL ALAN BOOSE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LEFFINGWELL AVE NE
GRAND RAPIDS MI
49525-6406
US

IV. Provider business mailing address

1111 LEFFINGWELL AVE NE
GRAND RAPIDS MI
49525-6406
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7101
  • Fax: 616-464-6170
Mailing address:
  • Phone: 616-459-7101
  • Fax: 616-464-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101026652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: