Healthcare Provider Details

I. General information

NPI: 1962908731
Provider Name (Legal Business Name): LAURA BOU-MAROUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

5340 DREW AVE S
MINNEAPOLIS MN
55410-2006
US

V. Phone/Fax

Practice location:
  • Phone: 734-740-1555
  • Fax:
Mailing address:
  • Phone: 347-401-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number77989
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number4301503999
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: