Basic Information
| Provider Information | |||||||||
| NPI: | 1811991177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUFFORD | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | PETER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36115 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344640887 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Practice Location | |||||||||
| Address1: | 15855 19 MILE RD | ||||||||
| Address2: | HENRY FORD MACOMB | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480383504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344640887 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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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 | 207R00000X | 4301062476 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 4301062476 | MI | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 70-0-F32947-0 | 01 | MI | BCBS CPIN # | OTHER | 4846333 | 05 | MI | MEDICAID | 1811991177 | 01 | MI | NPI # | OTHER | TB062476 | 01 | MI | BCBSM | OTHER |