Provider Demographics
NPI:1518948215
Name:BOSTICK, BEN GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:GREGORY
Last Name:BOSTICK
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 1:503 CLARK ST NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-1921
Mailing Address - Country:US
Mailing Address - Phone:256-739-1759
Mailing Address - Fax:256-739-0027
Practice Address - Street 1:408 CLARK ST NE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-1953
Practice Address - Country:US
Practice Address - Phone:256-734-3202
Practice Address - Fax:256-734-4668
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51026279OtherBCBS OF AL
AL000026279Medicaid
ALE869OtherMEDICARE GROUP #
AL000026279Medicaid
AL51026279OtherBCBS OF AL
AL080115441Medicare PIN