MEDICARE: ANTHONY GERARD BOSTAPH M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PS007937L	PA

General Provider Information

NPI Number	:	1093805418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY GERARD BOSTAPH M.A.

Provider Business Mailing Address
First Line	:	4402 PEACH ST
Second Line	:	LOWER LEVEL/ NORTH
City	:	ERIE
State	:	PA
Zip	:	16509-1358
Country	:	US
Telephone Number	:	814-868-0141
Fax Number	:	814-868-0142

Provider Business Practice Location Address
First Line	:	4402 PEACH ST
Second Line	:	LOWER LEVEL/ NORTH
City	:	ERIE
State	:	PA
Zip	:	16509-1358
Country	:	US
Telephone Number	:	814-868-0141
Fax Number	:	814-868-0142

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	07/08/2007

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