Healthcare Provider Details

I. General information

NPI: 1104056431
Provider Name (Legal Business Name): ROBERT RAYMOND BOESCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 BROADWAY SUITE 215
NEW YORK NY
10007-1823
US

IV. Provider business mailing address

290 BROADWAY SUITE 215
NEW YORK NY
10007-1823
US

V. Phone/Fax

Practice location:
  • Phone: 212-637-3003
  • Fax: 212-637-5155
Mailing address:
  • Phone: 212-637-3003
  • Fax: 212-637-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number114868
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: