Provider Demographics
NPI:1841435047
Name:BOSE, BRENT JERROD (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:JERROD
Last Name:BOSE
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 1:842 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:842 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7134
Practice Address - Country:US
Practice Address - Phone:541-618-5800
Practice Address - Fax:541-779-3027
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH157852085R0204X
ORMD1616622085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500657645Medicaid
R170676OtherMEDICARE