Provider Demographics
NPI:1861496622
Name:BOCCAROSSA, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BOCCAROSSA
Suffix:
Gender:F
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 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:240 MEDICAL PARK BLVD
Practice Address - Street 2:STE 3600
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7349
Practice Address - Country:US
Practice Address - Phone:423-990-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 29434207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5830508Medicaid
VA5830508Medicaid
TN3837341Medicare ID - Type Unspecified
0281780003Medicare PIN
TN3837340Medicare ID - Type Unspecified
VACC0450Medicare PIN
0281780001Medicare PIN