Healthcare Provider Details

I. General information

NPI: 1265408272
Provider Name (Legal Business Name): MARY BETH BOESON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

2006 HOGBACK RD STE 5A
ANN ARBOR MI
48105-9750
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-5000
  • Fax:
Mailing address:
  • Phone: 734-263-2395
  • Fax: 734-773-3471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704201092
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: