Healthcare Provider Details

I. General information

NPI: 1225036916
Provider Name (Legal Business Name): CLIFFORD KENT BOESE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EDMUNDSON PL STE 500
COUNCIL BLUFFS IA
51503-4619
US

IV. Provider business mailing address

1 EDMUNDSON PL STE 500
COUNCIL BLUFFS IA
51503-4619
US

V. Phone/Fax

Practice location:
  • Phone: 712-323-5333
  • Fax: 712-323-3252
Mailing address:
  • Phone: 712-323-5333
  • Fax: 712-323-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number19711
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number30053
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: