Provider Demographics
NPI:1992703672
Name:BOAL, JAMES SCOTT (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:SCOTT
Last Name:BOAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14100 NEWBURGH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5010
Mailing Address - Country:US
Mailing Address - Phone:734-464-7810
Mailing Address - Fax:734-779-4601
Practice Address - Street 1:14100 NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5010
Practice Address - Country:US
Practice Address - Phone:734-464-7810
Practice Address - Fax:734-779-4601
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301070040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H61819Medicare UPIN
MIN14770005Medicare ID - Type Unspecified