Provider Demographics
NPI:1235105685
Name:BOXUM, MICHAEL SCOTT (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:BOXUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 SILHAVY RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-9157
Mailing Address - Country:US
Mailing Address - Phone:219-465-3279
Mailing Address - Fax:
Practice Address - Street 1:754 MCCOOL RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-8856
Practice Address - Country:US
Practice Address - Phone:219-759-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003170A207Q00000X
MI5101014865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200860670AMedicaid
IN000000524369OtherANTHEM BLUE CROSS
IN200860670AMedicaid
IN251410Medicare PIN