Healthcare Provider Details

I. General information

NPI: 1902947799
Provider Name (Legal Business Name): CRAIG BRIAN BOSWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 N MASON RD SUITE 170
SAINT LOUIS MO
63141-6338
US

IV. Provider business mailing address

969 N MASON RD SUITE 170
SAINT LOUIS MO
63141-6338
US

V. Phone/Fax

Practice location:
  • Phone: 314-628-8200
  • Fax: 314-628-9504
Mailing address:
  • Phone: 314-628-8200
  • Fax: 314-628-9504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number108610
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: