Provider Demographics
NPI:1922370857
Name:BOESE, BRIAN CLARK (DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CLARK
Last Name:BOESE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:810-229-6140
Mailing Address - Fax:
Practice Address - Street 1:10415 GRAND RIVER RD STE 300
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-6533
Practice Address - Country:US
Practice Address - Phone:810-229-6140
Practice Address - Fax:810-229-6145
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004883225100000X
OR60259225100000X
MI5501018260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0349714OtherWA L&I
OR500697800Medicaid
ORP01740336OtherRR MEDICARE
OR0349714OtherWA L&I