Provider Demographics
NPI:1982672606
Name:BOOMER, ROBERT R (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:BOOMER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 375
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-662-4200
Mailing Address - Fax:248-662-0368
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 375
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-662-4200
Practice Address - Fax:248-662-0368
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-08-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301046392207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619335Medicaid
MI4619335Medicaid
N91620004Medicare ID - Type Unspecified