Provider Demographics
NPI:1891449195
Name:BOSCO, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BOSCO
Suffix:
Gender:M
Credentials:
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 30516
Mailing Address - Street 2:DEPT 5300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1335 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1555
Practice Address - Country:US
Practice Address - Phone:616-888-3184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501301744OtherSTATE LICENSE