Provider Demographics
NPI:1407840549
Name:MIKKILINENI, BOSE S (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:BOSE
Middle Name:S
Last Name:MIKKILINENI
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2805
Mailing Address - Country:US
Mailing Address - Phone:304-253-8416
Mailing Address - Fax:866-461-4726
Practice Address - Street 1:419 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-253-8416
Practice Address - Fax:866-461-4726
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12282208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720379OtherBCBS
WV020002556OtherRAILROAD MEDICARE
WV151389100OtherFEDERAL COMPENSATION #
WV550631859OtherTRICARE
WV68790Other68790
WV231835OtherMAMSI
WV49236OtherANTHEM BCBS
WV0128502000Medicaid
WV151389100OtherACS
WV6441144OtherCIGNA
WV550631859OtherTRICARE
WV0128502000Medicaid