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General NPI Number Information
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NPI Number | 1467520163
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Entity Type | Individual
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Provider Name | JEFFERY BOSSENBERGER D.O.
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Gender | Male
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 11/29/2018
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Provider Practice Location Address
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Address Line | 17200 SILVER PKWY
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City | FENTON
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State | MI
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Zip | 48430-4437
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Country | US
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Telephone | 810-714-9660
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Fax | 810-714-9661
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Provider Business Mailing Address
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Address Line | 17200 SILVER PKWY
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City | FENTON
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State | MI
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Zip | 48430-3423
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Country | US
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Telephone | 810-714-9660
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Fax | 810-714-9661
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5101012104
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License Number State | MI
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