Provider Demographics
NPI:1558351759
Name:XU, BO (MD)
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:XU
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:PO BOX 60100
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0100
Mailing Address - Country:US
Mailing Address - Phone:800-887-7338
Mailing Address - Fax:
Practice Address - Street 1:30 SHELBURNE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3628
Practice Address - Country:US
Practice Address - Phone:203-276-4067
Practice Address - Fax:203-276-7063
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159935207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1558351759Medicaid
CT1558351759Medicaid
P00336112Medicare PIN
H36415Medicare UPIN