Provider Demographics
NPI:1922120054
Name:JOHN L BOSSIAN
Entity Type:Organization
Organization Name:JOHN L BOSSIAN
Other - Org Name:MAIN STREET FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:BOSSIAN
Authorized Official - Suffix:II
Authorized Official - Credentials:DO
Authorized Official - Phone:401-789-1600
Mailing Address - Street 1:66 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3555
Mailing Address - Country:US
Mailing Address - Phone:401-789-1600
Mailing Address - Fax:
Practice Address - Street 1:66 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3555
Practice Address - Country:US
Practice Address - Phone:401-789-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO0391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMS46923OtherOTHER
RIMS46923Medicaid
RI089021307Medicare ID - Type Unspecified
RIMS46923Medicaid