Provider Demographics
NPI:1386879443
Name:VON BOSE, MICHAEL J (MD, FACEP)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:VON BOSE
Suffix:
Gender:M
Credentials:MD, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 1/2 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-2901
Mailing Address - Country:US
Mailing Address - Phone:917-375-7417
Mailing Address - Fax:
Practice Address - Street 1:4108 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5120
Practice Address - Country:US
Practice Address - Phone:718-252-2582
Practice Address - Fax:718-252-0598
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257611207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0934607Medicaid
NJ160003UWYMedicare PIN
NJ160003UXLMedicare PIN
NJ160003UXKMedicare PIN
NJ160003TM8Medicare PIN
NJ160003UWXMedicare PIN