Healthcare Provider Details

I. General information

NPI: 1376171728
Provider Name (Legal Business Name): SAMANTHA ALLISON BOSAK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RIDGE RD STE 1
NEWTON FALLS OH
44444-1264
US

IV. Provider business mailing address

340 RIDGE RD STE 1
NEWTON FALLS OH
44444-1264
US

V. Phone/Fax

Practice location:
  • Phone: 330-872-0330
  • Fax: 330-872-3033
Mailing address:
  • Phone: 330-872-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58.031511
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: