Healthcare Provider Details

I. General information

NPI: 1043625361
Provider Name (Legal Business Name): PHILLIP BOSTIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 MEDICAL PARK DR
HICKORY NC
28602-8809
US

IV. Provider business mailing address

2165 MEDICAL PARK DR
HICKORY NC
28602-8809
US

V. Phone/Fax

Practice location:
  • Phone: 828-294-7793
  • Fax: 828-294-9160
Mailing address:
  • Phone: 828-294-7793
  • Fax: 828-294-9160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number01084243B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberCV2002622
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2021-00032
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: