Healthcare Provider Details

I. General information

NPI: 1245775295
Provider Name (Legal Business Name): MICHAEL BOZUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2016
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S KEENE ST
COLUMBIA MO
65201-7199
US

IV. Provider business mailing address

PO BOX 7536
COLUMBIA MO
65205-7536
US

V. Phone/Fax

Practice location:
  • Phone: 573-445-7300
  • Fax: 573-445-7301
Mailing address:
  • Phone: 573-445-7300
  • Fax: 573-445-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2016043549
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: