Provider Demographics
NPI:1033495270
Name:BOSLEY, DERICK MICHAEL
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:MICHAEL
Last Name:BOSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 86 BOX 418C
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-9719
Mailing Address - Country:US
Mailing Address - Phone:301-697-2500
Mailing Address - Fax:
Practice Address - Street 1:1940 BOYD RD
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:SC
Practice Address - Zip Code:29591-5835
Practice Address - Country:US
Practice Address - Phone:843-389-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2348171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor