Healthcare Provider Details

I. General information

NPI: 1508034802
Provider Name (Legal Business Name): MARC BOSTICK MD CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N ALLUMBAUGH ST STE 101
BOISE ID
83704-9219
US

IV. Provider business mailing address

413 N ALLUMBAUGH ST STE 101
BOISE ID
83704-9219
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-1125
  • Fax: 208-323-9604
Mailing address:
  • Phone: 208-323-1125
  • Fax: 208-323-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM7712
License Number StateID

VIII. Authorized Official

Name: CHERI PETERSON
Title or Position: CREDENTIALER
Credential:
Phone: 208-954-5594