Healthcare Provider Details

I. General information

NPI: 1376551101
Provider Name (Legal Business Name): JOSE BOSSBALY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 DIAMOND ST
PHILADELPHIA PA
19122-1721
US

IV. Provider business mailing address

136 DIAMOND ST
PHILADELPHIA PA
19122-1721
US

V. Phone/Fax

Practice location:
  • Phone: 215-426-8100
  • Fax: 215-965-2344
Mailing address:
  • Phone: 215-426-8100
  • Fax: 215-965-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD040261L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: