MEDICARE: DR. JAMES BOMBARD

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	103TC0700X	Clinical Psychologist	6301000834	MI

General Provider Information

NPI Number	:	1780669028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES BOMBARD

Provider Business Mailing Address
First Line	:	5119 WILLOW POND DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2083
Country	:	US
Telephone Number	:	248-681-0189
Fax Number	:

Provider Business Practice Location Address
First Line	:	6777 W MAPLE RD
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3013
Country	:	US
Telephone Number	:	248-661-7917
Fax Number	:

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

Provider Enumeration Date	:	12/09/2005
Last Update Date	:	07/08/2007

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