Provider Demographics
NPI:1467574293
Name:J HOUSTON BOSLEY,M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:J HOUSTON BOSLEY,M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:HOUSTON
Authorized Official - Last Name:BOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-688-8801
Mailing Address - Street 1:2533 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3158
Mailing Address - Country:US
Mailing Address - Phone:318-688-8801
Mailing Address - Fax:318-688-8861
Practice Address - Street 1:2533 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 104
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3158
Practice Address - Country:US
Practice Address - Phone:318-688-8801
Practice Address - Fax:318-688-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06657R207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1799611Medicaid
LAB62019Medicare UPIN
LA56723Medicare ID - Type Unspecified
LA1799611Medicaid