Provider Demographics
NPI:1912950155
Name:BOESSENKOOL, ELIZABETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:BOESSENKOOL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 36TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3587
Mailing Address - Country:US
Mailing Address - Phone:616-534-1640
Mailing Address - Fax:616-534-4370
Practice Address - Street 1:950 36TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-3587
Practice Address - Country:US
Practice Address - Phone:616-534-1640
Practice Address - Fax:616-534-4370
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1921891Medicaid
MI1921891Medicaid