Healthcare Provider Details

I. General information

NPI: 1477382620
Provider Name (Legal Business Name): BOSWELL MEDICAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SE 2ND AVE STE 2000
MIAMI FL
33131-2185
US

IV. Provider business mailing address

333 SE 2ND AVE STE 2000
MIAMI FL
33131-2185
US

V. Phone/Fax

Practice location:
  • Phone: 401-300-5222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRYAN WANG
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 832-420-7667