Healthcare Provider Details

I. General information

NPI: 1346863750
Provider Name (Legal Business Name): JORDAN T BOIVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 S 11TH ST STE 201
KALAMAZOO MI
49009-2175
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 269-343-1535
  • Fax: 269-343-0418
Mailing address:
  • Phone: 269-552-2823
  • Fax: 269-552-2964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number4301517677
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351046936
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: