Healthcare Provider Details

I. General information

NPI: 1609526409
Provider Name (Legal Business Name): MICHAEL BOATENG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF PEDIATRIC ANESTHESIOLOGY
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

4742 PINE ST APT 102
PHILADELPHIA PA
19143-1965
US

V. Phone/Fax

Practice location:
  • Phone: 800-879-2467
  • Fax:
Mailing address:
  • Phone: 908-463-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberMT225275
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: