Healthcare Provider Details

I. General information

NPI: 1710965116
Provider Name (Legal Business Name): PHILIP J. BOSHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 HOSPITAL DR STE 112
STATE COLLEGE PA
16803-5500
US

IV. Provider business mailing address

PO BOX 858 MC A410
HERSHEY PA
17033-0858
US

V. Phone/Fax

Practice location:
  • Phone: 814-865-3566
  • Fax: 814-863-7803
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberL9632
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD420020
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMD420020
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: