Provider Demographics
NPI:1982679817
Name:BOSTROM, BRUCE C (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:BOSTROM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2910 CENTRE POINTE DR
Mailing Address - Street 2:35 121A CHILDRENS HEALTH CARE
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2109
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:2525 CHICAGO AVE S
Practice Address - Street 2:CHILDRENS SPECIALTY CLINIC HEMATOLOGY ONCOLOGY MPLS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-813-5940
Practice Address - Fax:612-813-6325
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN26111208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D82138Medicare UPIN