Healthcare Provider Details

I. General information

NPI: 1891725420
Provider Name (Legal Business Name): PAUL STEVEN BOARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/24/2024
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S 18TH AVE
STURGEON BAY WI
54235-1401
US

IV. Provider business mailing address

323 S 18TH AVE.
STURGEON BAY WI
54235
US

V. Phone/Fax

Practice location:
  • Phone: 920-746-0510
  • Fax: 920-746-3727
Mailing address:
  • Phone: 920-746-0510
  • Fax: 920-746-3727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number51493
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number51493-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: