Provider Demographics
NPI:1063440592
Name:BOSWORTH, QUINN M (DO)
Entity type:Individual
Prefix:DR
First Name:QUINN
Middle Name:M
Last Name:BOSWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1881 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1840
Mailing Address - Country:US
Mailing Address - Phone:517-339-2100
Mailing Address - Fax:517-339-4620
Practice Address - Street 1:1881 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1840
Practice Address - Country:US
Practice Address - Phone:517-339-2100
Practice Address - Fax:517-339-4620
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101014014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH13403Medicare UPIN