Provider Demographics
NPI:1386790939
Name:MARC E BOSEM MD PA
Entity type:Organization
Organization Name:MARC E BOSEM MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOSEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-437-9300
Mailing Address - Street 1:2300 N COMMERCE PKWY STE 308
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3256
Mailing Address - Country:US
Mailing Address - Phone:954-442-1133
Mailing Address - Fax:
Practice Address - Street 1:2300 N COMMERCE PKWY STE 308
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3256
Practice Address - Country:US
Practice Address - Phone:954-442-1133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067977156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1801857685OtherDR. KHAN NPI
FL378399500Medicaid
FL1710929039OtherDR. MAX CORNDORF
FLH75931Medicare UPIN
FLU8596ZMedicare ID - Type UnspecifiedDR. KHAN
FL1710929039OtherDR. MAX CORNDORF