Provider Demographics
NPI:1225276371
Name:BOSI, RANDAL GENE (OTR)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:GENE
Last Name:BOSI
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 WINDROSE CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7587
Mailing Address - Country:US
Mailing Address - Phone:920-883-1808
Mailing Address - Fax:
Practice Address - Street 1:600 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3503
Practice Address - Country:US
Practice Address - Phone:920-432-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3007-026225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation