Provider Demographics
NPI:1124141171
Name:DR. BOSE S. MIKKILINENI, M.D. FACS
Entity type:Organization
Organization Name:DR. BOSE S. MIKKILINENI, M.D. FACS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BOSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MIKKILINENI, M.D. FACS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-253-8416
Mailing Address - Street 1:419 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2805
Mailing Address - Country:US
Mailing Address - Phone:304-253-8416
Mailing Address - Fax:866-461-4726
Practice Address - Street 1:419 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-253-8416
Practice Address - Fax:866-461-4726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV12282208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0128502000Medicaid
WV0128502000Medicaid
WV0128502000Medicaid
WV0532523Medicare PIN