Provider Demographics
NPI:1972665735
Name:BOSSERT, MATTHEW THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BOSSERT
Suffix:
Gender:M
Credentials:DC
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 495
Mailing Address - Street 2:
Mailing Address - City:BEECH CREEK
Mailing Address - State:PA
Mailing Address - Zip Code:16822
Mailing Address - Country:US
Mailing Address - Phone:570-962-3075
Mailing Address - Fax:570-962-2573
Practice Address - Street 1:354 EAGLE VALLEY DRIVE
Practice Address - Street 2:
Practice Address - City:BEECH CREEK
Practice Address - State:PA
Practice Address - Zip Code:16822
Practice Address - Country:US
Practice Address - Phone:570-962-3075
Practice Address - Fax:570-962-2573
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005777L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA017100280002Medicaid
PAB0862349OtherBLUE CROSS
PAB0862349OtherBLUE CROSS
PA017100280002Medicaid