1477021160 NPI number — LISA JANE BOSIO

Table of content: LISA JANE BOSIO (NPI 1477021160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477021160 NPI number — LISA JANE BOSIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSIO
Provider First Name:
LISA
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477021160
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DR LBBY C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-647-5871
Provider Business Mailing Address Fax Number:
734-647-2145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 FRANK LLOYD WRIGHT DR LBBY C
Provider Second Line Business Practice Location Address:
STE 1300
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48105-9484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-647-5871
Provider Business Practice Location Address Fax Number:
734-647-2145
Provider Enumeration Date:
11/12/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X , with the licence number:  4704169802 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)