Healthcare Provider Details

I. General information

NPI: 1528061702
Provider Name (Legal Business Name): ERIC WILLIAM BOOSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 ROCKSIDE RD STE 260
INDEPENDENCE OH
44131-2351
US

IV. Provider business mailing address

6701 ROCKSIDE RD STE 260
INDEPENDENCE OH
44131-2351
US

V. Phone/Fax

Practice location:
  • Phone: 216-369-2525
  • Fax: 216-369-2531
Mailing address:
  • Phone: 216-369-2525
  • Fax: 216-369-2531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35081506B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: