Provider Demographics
NPI:1902850381
Name:VANDEN BOSCHE, ROBERT CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHARLES
Last Name:VANDEN BOSCHE
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 1:6501 BALTIMORE NATIONAL PIKE STE D
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3923
Mailing Address - Country:US
Mailing Address - Phone:667-234-2100
Mailing Address - Fax:667-234-2944
Practice Address - Street 1:6501 BALTIMORE NATIONAL PIKE STE D
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-3923
Practice Address - Country:US
Practice Address - Phone:667-234-2100
Practice Address - Fax:667-234-2944
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57461207Q00000X
PAMD060456L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD699737600Medicaid
MD080188341OtherRAILROAD
MD699737600Medicaid
MDG60915Medicare UPIN
MD613LMedicare ID - Type UnspecifiedMEDICARE GRP #
MD699737600Medicaid