Provider Demographics
NPI:1154377893
Name:BOSELLI, JOSEPH MARK (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MARK
Last Name:BOSELLI
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 1:205 NORTH BROAD STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-587-8008
Mailing Address - Fax:215-587-6248
Practice Address - Street 1:205 NORTH BROAD STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-587-8008
Practice Address - Fax:215-587-6248
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030504E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1048608010Medicaid
C29437Medicare UPIN
PA1048608010Medicaid