Provider Demographics
NPI:1720085228
Name:BOSWELL, JOHN I III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:I
Last Name:BOSWELL
Suffix:III
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 1:1315 W COLLEGE AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-2776
Mailing Address - Country:US
Mailing Address - Phone:814-861-3300
Mailing Address - Fax:
Practice Address - Street 1:1315 W COLLEGE AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2776
Practice Address - Country:US
Practice Address - Phone:814-861-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA035090-E2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010576160010Medicaid
PABO650710Medicare ID - Type Unspecified