Provider Demographics
NPI:1376551101
Name:BOSSBALY, JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:BOSSBALY
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 1:136 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-1721
Mailing Address - Country:US
Mailing Address - Phone:215-426-8100
Mailing Address - Fax:215-965-2344
Practice Address - Street 1:136 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-1721
Practice Address - Country:US
Practice Address - Phone:215-426-8100
Practice Address - Fax:215-965-2344
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040261L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA056930GUGMedicare PIN
PAB34540Medicare UPIN
PA056930Medicare PIN