Healthcare Provider Details

I. General information

NPI: 1801807144
Provider Name (Legal Business Name): JERALD P BOSEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S OREM BLVD STE 103
OREM UT
84058-3006
US

IV. Provider business mailing address

121 S OREM BLVD STE 103
OREM UT
84058-3006
US

V. Phone/Fax

Practice location:
  • Phone: 801-225-4911
  • Fax: 801-225-4854
Mailing address:
  • Phone: 801-225-4911
  • Fax: 801-225-4854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number48849
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number48108
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number5929764-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier29025354
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
Identifier3007868
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 3
Identifier055435000
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: