MEDICARE: RICKY BOLDMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601001019	MI

General Provider Information

NPI Number	:	1437126323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICKY BOLDMAN

Provider Business Mailing Address
First Line	:	461 W HURON ST
Second Line	:	SUITE 207
City	:	PONTIAC
State	:	MI
Zip	:	48341-1601
Country	:	US
Telephone Number	:	248-857-7160
Fax Number	:

Provider Business Practice Location Address
First Line	:	461 W HURON ST
Second Line	:	SUITE 207
City	:	PONTIAC
State	:	MI
Zip	:	48341-1601
Country	:	US
Telephone Number	:	248-857-7160
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	07/16/2007

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Directions to “ RICKY BOLDMAN ” Practice Location

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