Provider Demographics
NPI:1932313798
Name:BORIBOON PEDIATRICS
Entity Type:Organization
Organization Name:BORIBOON PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KINGKHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORIBOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-562-9500
Mailing Address - Street 1:3850 PELHAM ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3832
Mailing Address - Country:US
Mailing Address - Phone:313-562-9500
Mailing Address - Fax:313-562-7567
Practice Address - Street 1:3850 PELHAM ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3832
Practice Address - Country:US
Practice Address - Phone:313-562-9500
Practice Address - Fax:313-562-7567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID
MI=========OtherTAX ID