Provider Demographics
NPI:1710190228
Name:EDWARD H BOSEKER MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD H BOSEKER MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOSEKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-558-6805
Mailing Address - Street 1:801 NORTH TUSTIN AVENUE
Mailing Address - Street 2:SUITE 507
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:714-558-6805
Mailing Address - Fax:714-558-1660
Practice Address - Street 1:801 NORTH TUSTIN AVENUE
Practice Address - Street 2:SUITE 507
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:714-558-6805
Practice Address - Fax:714-558-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28780207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18310Medicare ID - Type Unspecified
A33739Medicare UPIN