Provider Demographics
NPI:1528228962
Name:MICHAEL EDWARD BOYKIN, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL EDWARD BOYKIN, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BOYKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-966-6530
Mailing Address - Street 1:3418 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2376
Mailing Address - Country:US
Mailing Address - Phone:318-966-6530
Mailing Address - Fax:318-966-6531
Practice Address - Street 1:2110 JUSTICE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3618
Practice Address - Country:US
Practice Address - Phone:318-322-8811
Practice Address - Fax:318-966-6531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010982261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1148113Medicaid
LAB60324Medicare UPIN
LA1148113Medicaid