1104881408 NPI number — OWEN G BOSSMAN MD

Table of content: OWEN G BOSSMAN MD (NPI 1104881408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104881408 NPI number — OWEN G BOSSMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSSMAN
Provider First Name:
OWEN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1104881408
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6255 SHERIDAN DR
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-4836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-857-8666
Provider Business Mailing Address Fax Number:
716-857-8944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14203-1149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-857-8625
Provider Business Practice Location Address Fax Number:
716-250-5961
Provider Enumeration Date:
04/19/2006

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: 207R00000X , with the licence number:  090635-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0001001840 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00481085 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 090635-4B . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2800146 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000502176001 . This is a "HEALTH NOW" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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