Healthcare Provider Details

I. General information

NPI: 1912001314
Provider Name (Legal Business Name): BONIFACE A. TUBIE, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

6915 DOBBS WAY
WEST BLOOMFIELD MI
48322-3077
US

V. Phone/Fax

Practice location:
  • Phone: 248-395-2206
  • Fax: 248-395-0456
Mailing address:
  • Phone: 248-592-1518
  • Fax: 248-395-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301072901
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number43010729901
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code246ZN0300X
TaxonomyNephrology Specialist/Technologist
License Number4301072901
License Number StateMI

VIII. Authorized Official

Name: DR. BONIFACE ATAKEKOR TUBIE
Title or Position: PHYSICIAN/ CEO
Credential: M.D.
Phone: 248-395-2206