Provider Demographics
NPI:1740564681
Name:BOARDMAN FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:BOARDMAN FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:KREYKES
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:231-624-1054
Mailing Address - Street 1:4713 PINE ST SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOARDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49680-9761
Mailing Address - Country:US
Mailing Address - Phone:231-518-0189
Mailing Address - Fax:231-518-0188
Practice Address - Street 1:4713 PINE ST SW
Practice Address - Street 2:
Practice Address - City:SOUTH BOARDMAN
Practice Address - State:MI
Practice Address - Zip Code:49680-9761
Practice Address - Country:US
Practice Address - Phone:231-518-0189
Practice Address - Fax:231-518-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013379207Q00000X
261QR1300X
MI5601002729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238901Medicare Oscar/Certification