Basic Information
| Provider Information | |||||||||
| NPI: | 1437299724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOBO | ||||||||
| FirstName: | ANDRE' | ||||||||
| MiddleName: | TYRONE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26703 SENATOR BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480345606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483500777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4727 SAINT ANTOINE ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137450499 | ||||||||
| FaxNumber: | 3138338801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 10/26/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 430166276 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 160H232190 | 01 | MI | BCBSM/BCN | OTHER | 104728939 | 05 | MI | MEDICAID |