Provider Demographics
NPI:1710965116
Name:BOSHA, PHILIP J (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:BOSHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:1850 E PARK AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6706
Practice Address - Country:US
Practice Address - Phone:814-865-3566
Practice Address - Fax:814-863-7803
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9632207QS0010X
PAMD420020207XX0005X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016695050001Medicaid
TX173210901Medicaid
PA103542NZ3OtherMEDICARE