Provider Demographics
NPI:1225000912
Name:BOEVE, THEODORE J (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:BOEVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E SHERMAN BLVD STE 309
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1850
Mailing Address - Country:US
Mailing Address - Phone:231-672-8643
Mailing Address - Fax:231-672-8651
Practice Address - Street 1:1560 E SHERMAN BLVD STE 309
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1850
Practice Address - Country:US
Practice Address - Phone:231-672-8643
Practice Address - Fax:231-672-8651
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077552208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104734613Medicaid
MIH37304Medicare UPIN
MI0D16173011Medicare ID - Type Unspecified