Provider Demographics
NPI:1891725420
Name:BOARD, PAUL STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:STEVEN
Last Name:BOARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S 18TH AVE.
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235
Mailing Address - Country:US
Mailing Address - Phone:920-746-0510
Mailing Address - Fax:920-746-3727
Practice Address - Street 1:323 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1401
Practice Address - Country:US
Practice Address - Phone:920-746-0510
Practice Address - Fax:920-746-3727
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51493207RA0401X, 207RA0401X
WI51493-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067276Medicaid
ILL88724Medicare ID - Type Unspecified
IL036067276Medicaid