Healthcare Provider Details

I. General information

NPI: 1942312921
Provider Name (Legal Business Name): CARL EUGENE BOSLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 LUCY LEE PKWY
POPLAR BLUFF MO
63901-2444
US

IV. Provider business mailing address

2503 LUCY LEE PKWY
POPLAR BLUFF MO
63901-2444
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-5544
  • Fax: 573-785-4672
Mailing address:
  • Phone: 573-785-5544
  • Fax: 573-785-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR8584
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberR8584
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: