Healthcare Provider Details

I. General information

NPI: 1164777595
Provider Name (Legal Business Name): BOOS, STANLEY, C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 OAKMONT ST
PHILADELPHIA PA
19152
US

IV. Provider business mailing address

2001 OAKMONT ST
PHILADELPHIA PA
19152
US

V. Phone/Fax

Practice location:
  • Phone: 215-745-5577
  • Fax: 215-765-6281
Mailing address:
  • Phone: 215-745-5577
  • Fax: 215-765-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STANLEY C BOOS
Title or Position: OWNER
Credential: D.O.
Phone: 215-745-5577