MEDICARE: DR. ERNEST BOSWELL PH.D.

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	103TC0700X	Clinical Psychologist	LP0771	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	91D05BO	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1437155801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERNEST BOSWELL PH.D.

Provider Business Mailing Address
First Line	:	1478 STERLING ST N
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55119-7179
Country	:	US
Telephone Number	:	651-330-8610
Fax Number	:	651-330-8610

Provider Business Practice Location Address
First Line	:	1478 STERLING ST N
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55119-7179
Country	:	US
Telephone Number	:	651-330-8610
Fax Number	:	651-330-8610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	07/08/2007

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