Provider Demographics
NPI:1225038698
Name:BOSE, SANJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:BOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-415-7653
Mailing Address - Fax:270-575-8359
Practice Address - Street 1:2601 KENTUCKY AVE STE 402
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3827
Practice Address - Country:US
Practice Address - Phone:270-575-3113
Practice Address - Fax:270-575-3135
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-095984207R00000X, 207RC0000X, 207UN0901X
KY43907207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095984Medicaid
KY7100164760Medicaid
IL036095984Medicaid
KYP01476013Medicare PIN
KYK074872Medicare PIN
KY7100164760Medicaid
ILL68885Medicare PIN