Provider Demographics
NPI:1043340714
Name:BOSE, BETHEL C (CNM)
Entity Type:Individual
Prefix:
First Name:BETHEL
Middle Name:C
Last Name:BOSE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2505
Mailing Address - Country:US
Mailing Address - Phone:812-238-7301
Mailing Address - Fax:812-238-7056
Practice Address - Street 1:1801 N 6TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4086
Practice Address - Country:US
Practice Address - Phone:812-238-7301
Practice Address - Fax:812-238-7056
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000025A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941090Z1Medicare PIN
IN130910AAMedicare PIN
IN252060VMedicare PIN
IN854700BBBBMedicare PIN