Basic Information
| Provider Information | |||||||||
| NPI: | 1316909773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOILEAU | ||||||||
| FirstName: | MICHEL | ||||||||
| MiddleName: | ADEODAT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2090 NE WYATT CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413826447 | ||||||||
| FaxNumber: | 5413307413 | ||||||||
| Practice Location | |||||||||
| Address1: | 2090 NE WYATT CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413826447 | ||||||||
| FaxNumber: | 5413307413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208800000X | MD09307 | OR | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 128207 | 05 | OR | MEDICAID |