Healthcare Provider Details

I. General information

NPI: 1821144577
Provider Name (Legal Business Name): BONIFACE ATAKEKOR TUBIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20755 GREENFIELD RD SUITE # 203
SOUTHFIELD MI
48075-5403
US

IV. Provider business mailing address

20755 GREENFIELD RD SUITE # 203
SOUTHFIELD MI
48075-5403
US

V. Phone/Fax

Practice location:
  • Phone: 248-395-2206
  • Fax: 248-395-0456
Mailing address:
  • Phone: 248-395-2206
  • Fax: 248-395-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301072901
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code246ZN0300X
TaxonomyNephrology Specialist/Technologist
License Number4301072901
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301072901
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: