MEDICARE: CHEZ THERESE MEDICAL CENTER PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1144791351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHEZ THERESE MEDICAL CENTER PA

Provider Business Mailing Address
First Line	:	4849 N MESA ST STE 201
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-5919
Country	:	US
Telephone Number	:	915-351-6600
Fax Number	:	915-351-6601

Provider Business Practice Location Address
First Line	:	6955 N MESA ST STE 101
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-4424
Country	:	US
Telephone Number	:	915-613-3010
Fax Number	:	915-201-1253

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AUGUSTINE O BOSAH
Credential	:	MD
Telephone Number	:	276-274-2144

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	11/18/2021

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