Provider Demographics
NPI:1720426240
Name:BOOSALIS, BRONSON (MD)
Entity Type:Individual
Prefix:
First Name:BRONSON
Middle Name:
Last Name:BOOSALIS
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 1:7500 MERCY RD
Mailing Address - Street 2:ATTN: EMERGENCY DEPARTMENT
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2319
Mailing Address - Country:US
Mailing Address - Phone:402-398-6060
Mailing Address - Fax:
Practice Address - Street 1:7500 MERCY RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2319
Practice Address - Country:US
Practice Address - Phone:402-559-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE28607207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE28607OtherSTATE OF NEBRASKA