Healthcare Provider Details

I. General information

NPI: 1194302679
Provider Name (Legal Business Name): STEVEN JON BOSC II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 BROAD ST
SUMTER SC
29150-4167
US

IV. Provider business mailing address

689 WHITE PINE WAY
SUMTER SC
29154-6214
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax:
Mailing address:
  • Phone: 843-568-9939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMPA.3910
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: