Basic Information
| Provider Information | |||||||||
| NPI: | 1225061732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637272 | ||||||||
| FaxNumber: | 6163637290 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198364569 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 01068422A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 01068422A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200987570 | 05 | IN | MEDICAID |