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General NPI Number Information
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NPI Number | 1124141171
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Entity Type | Organization
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Legal Business Name | DR. BOSE S. MIKKILINENI, M.D. FACS
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 01/02/2013
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Provider Practice Location Address
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Address Line | 419 CARRIAGE DR
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City | BECKLEY
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State | WV
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Zip | 25801-2805
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Country | US
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Telephone | 304-253-8416
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Fax | 866-461-4726
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Provider Business Mailing Address
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Address Line | 419 CARRIAGE DR
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City | BECKLEY
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State | WV
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Zip | 25801-2805
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Country | US
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Telephone | 304-253-8416
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Fax | 866-461-4726
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | DR. BOSE S MIKKILINENI, M.D. FACS
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Credential | M.D.
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Telephone | 304-253-8416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | WV12282
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License Number State | WV
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