Provider Demographics
NPI:1861002131
Name:PORT HURON BONE AND JOINT SURGERY PC
Entity Type:Organization
Organization Name:PORT HURON BONE AND JOINT SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-451-9692
Mailing Address - Street 1:1330 CONGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3005
Mailing Address - Country:US
Mailing Address - Phone:734-451-9692
Mailing Address - Fax:734-451-9606
Practice Address - Street 1:1985 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2215
Practice Address - Country:US
Practice Address - Phone:734-451-9692
Practice Address - Fax:734-451-9606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-03
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861002131Medicaid