Basic Information
Provider Information | |||||||||
NPI: | 1932192994 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOSSHARDT | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1949 GUNBARREL ROAD | ||||||||
Address2: | SUITE 230 | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 37421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234954345 | ||||||||
FaxNumber: | 4234952625 | ||||||||
Practice Location | |||||||||
Address1: | 2525 DESALES AVENUE | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 37404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234952525 | ||||||||
FaxNumber: | 4234952625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2005 | ||||||||
LastUpdateDate: | 04/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 021372 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 026225 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00285612A | 05 | GA |   | MEDICAID | 52270883 | 01 | GA | BCBS OF GEORGIA | OTHER | 35544 | 01 | TN | BCBS OF TENNESSEE | OTHER |