Provider Demographics
NPI:1326044710
Name:MICHAEL M BOUSTANY MD INC
Entity Type:Organization
Organization Name:MICHAEL M BOUSTANY MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOUSTANY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-343-7557
Mailing Address - Street 1:PO BOX 3850
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25338-3850
Mailing Address - Country:US
Mailing Address - Phone:304-233-9314
Mailing Address - Fax:304-233-0265
Practice Address - Street 1:415 MORRIS ST
Practice Address - Street 2:STE 105
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1840
Practice Address - Country:US
Practice Address - Phone:304-343-7557
Practice Address - Fax:304-343-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10600208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2065901Medicaid
KY6953086900Medicaid
KY6953086900Medicaid