Healthcare Provider Details

I. General information

NPI: 1578205456
Provider Name (Legal Business Name): CLARA MARIE BOSCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

4231 WILLOW BROOK RD
DE PERE WI
54115-9232
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-2000
  • Fax:
Mailing address:
  • Phone: 920-857-0197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.086862
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: