Basic Information
| Provider Information | |||||||||
| NPI: | 1245855667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOULTER | ||||||||
| FirstName: | JOSHUA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 PROVIDENCE DRIVE | ||||||||
| Address2: | 3PMB SUITE #301 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493281 | ||||||||
| FaxNumber: | 2488495449 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 PROVIDENCE DRIVE | ||||||||
| Address2: | 3PMB SUITE #301 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493281 | ||||||||
| FaxNumber: | 2488495449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2020 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 1245855667 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.