Provider Demographics
NPI:1295721637
Name:BOSLEY, ROGER (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BOSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2971
Mailing Address - Country:US
Mailing Address - Phone:765-447-6969
Mailing Address - Fax:765-449-0229
Practice Address - Street 1:2316 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2971
Practice Address - Country:US
Practice Address - Phone:765-447-6969
Practice Address - Fax:765-449-0229
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01025102A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E03847Medicare UPIN