Basic Information
| Provider Information | |||||||||
| NPI: | 1285209015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSCO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | V. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082734300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 PLEASANT VALLEY WAY | ||||||||
| Address2: | |||||||||
| City: | WEST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070522956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736695600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2021 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 25MP00632600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.