Provider Demographics
NPI:1487720967
Name:BOSSE, BRUCE ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ERIC
Last Name:BOSSE
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 1:2500 HOSPITAL BLVD
Mailing Address - Street 2:STE 440
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:770-663-4649
Mailing Address - Fax:770-663-3930
Practice Address - Street 1:2500 HOSPITAL BLVD
Practice Address - Street 2:STE 440
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-663-4649
Practice Address - Fax:770-663-3930
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA345032084N0400X
AL000141192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00465132BMedicaid
E14394Medicare UPIN
GA00465132BMedicaid