Provider Demographics
NPI:1013900646
Name:BOSS, ROBERT J (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:BOSS
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 397
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OR
Mailing Address - Zip Code:97818
Mailing Address - Country:US
Mailing Address - Phone:541-481-7212
Mailing Address - Fax:541-481-2020
Practice Address - Street 1:450 TATONE STREET
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OR
Practice Address - Zip Code:97818
Practice Address - Country:US
Practice Address - Phone:541-481-7212
Practice Address - Fax:541-481-2020
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09837207R00000X
ORMD00017375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004015Medicaid
OR011WCJMMAMedicare ID - Type Unspecified
C91570Medicare UPIN
OR004015Medicaid