Basic Information
| Provider Information | |||||||||
| NPI: | 1710965116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSHA | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 858 | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002431455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1850 E PARK AVE | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168036706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148653566 | ||||||||
| FaxNumber: | 8148637803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | L9632 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207XX0005X | MD420020 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XS0114X | MD420020 | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1016695050001 | 05 | PA | MEDICAID | 173210901 | 05 | TX | MEDICAID | 103542NZ3 | 01 | PA | MEDICARE | OTHER |