Provider Demographics
NPI:1902850274
Name:BOSTOM, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BOSTOM
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 1358
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:APC 9
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-6460
Practice Address - Fax:401-444-2217
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09437207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2100339Medicaid
RI9025311Medicaid
RIP00024512OtherRAILROAD MEDICARE
RI007056322Medicare PIN