Provider Demographics
NPI: | 1841204310 |
---|---|
Name: | BOSSE, MICHAEL (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | |
Last Name: | BOSSE |
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 19305 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28219-9305 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1025 MOREHEAD MEDICAL DR |
Practice Address - Street 2: | STE 300 |
Practice Address - City: | CHARLOTTE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28204-2963 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-355-5982 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-28 |
Last Update Date: | 2020-09-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 9300425 | 207X00000X |
NC | 009300425 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 1699A | Other | NCBCBS |
NC | 1841204310 | Medicaid | |
NC | 891699A | Medicaid | |
SC | N00425 | Medicaid | |
NC | 2195069A | Medicare PIN | |
NC | 1699A | Other | NCBCBS |
NC | P00410575 | Medicare PIN | |
NC | 891699A | Medicaid | |
NC | 1841204310 | Medicaid |