Provider Demographics
NPI:1124024708
Name:BOSOMWORTH, REBECCA G (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:G
Last Name:BOSOMWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 ALEXANDRIA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3149
Mailing Address - Country:US
Mailing Address - Phone:859-277-3490
Mailing Address - Fax:859-278-5014
Practice Address - Street 1:1701 ALEXANDRIA DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3149
Practice Address - Country:US
Practice Address - Phone:859-277-3490
Practice Address - Fax:859-278-5014
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30547208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64076706Medicaid