Healthcare Provider Details

I. General information

NPI: 1760863773
Provider Name (Legal Business Name): ELIZABETH BOES D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 E 12 MILE RD
WARREN MI
48093-3570
US

IV. Provider business mailing address

12000 E 12 MILE RD
WARREN MI
48093-3570
US

V. Phone/Fax

Practice location:
  • Phone: 586-576-4140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101021837
License Number StateMH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: