Provider Demographics
NPI:1245657444
Name:BOSWORTH, MICHAEL C (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:BOSWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON ST STE 401
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02481-1737
Mailing Address - Country:US
Mailing Address - Phone:781-416-3500
Mailing Address - Fax:781-416-3505
Practice Address - Street 1:1 WASHINGTON ST STE 401
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-1737
Practice Address - Country:US
Practice Address - Phone:814-163-5007
Practice Address - Fax:781-416-3505
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA263766207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110106301AMedicaid