Provider Demographics
NPI:1154780831
Name:BOSE PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:BOSE PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOHITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-317-2872
Mailing Address - Street 1:85 E US HIGHWAY 6
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-8947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85 E US HIGHWAY 6
Practice Address - Street 2:SUITE 210
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8947
Practice Address - Country:US
Practice Address - Phone:562-317-2872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3073Medicare PIN