Provider Demographics
NPI:1124011291
Name:BOUVIER, ROBERT M JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:BOUVIER
Suffix:JR
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 1:12741 S SAGINAW ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2460
Mailing Address - Country:US
Mailing Address - Phone:810-694-7412
Mailing Address - Fax:866-200-1503
Practice Address - Street 1:12741 S SAGINAW ST
Practice Address - Street 2:SUITE 402
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2460
Practice Address - Country:US
Practice Address - Phone:810-694-7412
Practice Address - Fax:866-200-1503
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3111774Medicaid
MIB45458Medicare UPIN
MI3111774Medicaid