Healthcare Provider Details

I. General information

NPI: 1972657690
Provider Name (Legal Business Name): TODD K BOSTWICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 LAKESHORE DR
ISHPEMING MI
49849-1367
US

IV. Provider business mailing address

2837 US 41 W
MARQUETTE MI
49855-2252
US

V. Phone/Fax

Practice location:
  • Phone: 906-486-4431
  • Fax:
Mailing address:
  • Phone: 906-225-3964
  • Fax: 906-226-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301073668
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: