Provider Demographics
NPI:1912982141
Name:BOSARGE, PATRICK L (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:L
Last Name:BOSARGE
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 1:1711 N MCKENZIE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2282
Mailing Address - Country:US
Mailing Address - Phone:251-952-6597
Mailing Address - Fax:251-424-1621
Practice Address - Street 1:1711 N MCKENZIE ST STE 201
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2282
Practice Address - Country:US
Practice Address - Phone:251-952-6597
Practice Address - Fax:251-424-1621
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46978208600000X
AL24252208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522312Medicaid
TN1522312Medicaid
TN103IO27480Medicare PIN