Provider Demographics
NPI:1588755714
Name:MANOO BOONSIRI,M.D.,P.C.
Entity type:Organization
Organization Name:MANOO BOONSIRI,M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANOO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONSIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-243-5822
Mailing Address - Street 1:730 N MACOMB ST
Mailing Address - Street 2:SUITE 415
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2900
Mailing Address - Country:US
Mailing Address - Phone:734-243-5822
Mailing Address - Fax:734-241-3350
Practice Address - Street 1:10501 TELEGRAPH RD
Practice Address - Street 2:SUITE 102
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3375
Practice Address - Country:US
Practice Address - Phone:313-295-7822
Practice Address - Fax:734-241-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI35446208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1798170Medicaid
MI3305801051OtherBLUECROSS BLUESHIELD MI
A75420Medicare UPIN
MI3305801051OtherBLUECROSS BLUESHIELD MI