Provider Demographics
NPI:1306008669
Name:BOSANQUET, JILL MELISSA (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MELISSA
Last Name:BOSANQUET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MELISSA
Other - Last Name:ANTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7421 HIGHWAY N
Practice Address - Street 2:
Practice Address - City:DARDENNE PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63368
Practice Address - Country:US
Practice Address - Phone:636-561-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011003923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360520Medicare PIN