Provider Demographics
NPI:1629046842
Name:BOSCH, ORTELIO (MD)
Entity Type:Individual
Prefix:
First Name:ORTELIO
Middle Name:
Last Name:BOSCH
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 1:7450 SKIDAWAY RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-6446
Mailing Address - Country:US
Mailing Address - Phone:912-233-6811
Mailing Address - Fax:912-544-0864
Practice Address - Street 1:7450 SKIDAWAY RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-6446
Practice Address - Country:US
Practice Address - Phone:912-233-6811
Practice Address - Fax:912-544-0864
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051119207L00000X
GA51119208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000966193DMedicaid
GAH66885Medicare UPIN