Provider Demographics
NPI:1437126323
Name:BOLDMAN, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:BOLDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 W HURON ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1601
Mailing Address - Country:US
Mailing Address - Phone:248-857-7160
Mailing Address - Fax:
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:SUITE 207
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP37067Medicare UPIN