Provider Demographics
NPI:1649266412
Name:BOSO, EDWIN BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:BRIAN
Last Name:BOSO
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 1:601 AVERY ST STE 501
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5192
Mailing Address - Country:US
Mailing Address - Phone:304-422-3904
Mailing Address - Fax:304-422-3924
Practice Address - Street 1:800 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5376
Practice Address - Country:US
Practice Address - Phone:304-424-2590
Practice Address - Fax:304-422-3924
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070251207L00000X
WV15116207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0041118000Medicaid
OH0784183Medicaid
E41205Medicare UPIN
0603444Medicare ID - Type Unspecified
0603445Medicare ID - Type Unspecified
WV0041118000Medicaid
OH0784183Medicaid