=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417950270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID BRUCE BOSSCHER D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 10/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 336 S RIVER AVE
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49423-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-394-3788
-----------------------------------------------------
Fax | 616-394-3796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MICHIGAN ST NE MC 845
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-2560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 02533
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 1238
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 510100847
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------