Provider Demographics
NPI:1154320968
Name:BOOS, STANLEY L (DO)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:L
Last Name:BOOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 OAKMONT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-4015
Mailing Address - Country:US
Mailing Address - Phone:215-745-5577
Mailing Address - Fax:215-765-6281
Practice Address - Street 1:2001 OAKMONT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-4015
Practice Address - Country:US
Practice Address - Phone:215-745-5577
Practice Address - Fax:215-765-6281
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S-OO4210-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006014400001Medicaid
PA0006014400001Medicaid
BO-103156Medicare ID - Type Unspecified