Provider Demographics
NPI:1740440916
Name:BOSSAK, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BOSSAK
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 1:4700 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-8180
Mailing Address - Fax:912-350-8427
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-8180
Practice Address - Fax:912-350-8427
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066457208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00955092OtherRAILROAD MEDICARE
GA003111162AMedicaid
GA01457468OtherAMERIGROUP
GA624791OtherWELLCARE
SCGA1236Medicaid
GA202I372860Medicare PIN