1336674803 NPI number — MATTHEW BOSARGE D.O.

Table of content: MATTHEW BOSARGE D.O. (NPI 1336674803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336674803 NPI number — MATTHEW BOSARGE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSARGE
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1336674803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 HIGHWAY 90
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAUTIER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39553-5340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-497-7576
Provider Business Mailing Address Fax Number:
228-497-8869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2819 DENNY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCAGOULA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39581-5301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-762-3466
Provider Business Practice Location Address Fax Number:
228-762-6349
Provider Enumeration Date:
04/21/2017

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: 207Q00000X , with the licence number:  27716 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00371202 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".