Provider Demographics
NPI:1730167644
Name:TRIFUNOVIC, BORIVOJE (MD)
Entity type:Individual
Prefix:
First Name:BORIVOJE
Middle Name:
Last Name:TRIFUNOVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25710 KELLY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4959
Mailing Address - Country:US
Mailing Address - Phone:586-772-2600
Mailing Address - Fax:586-772-5289
Practice Address - Street 1:25710 KELLY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4959
Practice Address - Country:US
Practice Address - Phone:586-772-2600
Practice Address - Fax:586-772-5289
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080193207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4772374Medicaid
MI1730167644OtherNPI
MI4784212Medicaid
I40319Medicare UPIN