Basic Information
| Provider Information | |||||||||
| NPI: | 1083738181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOZARTH ORTHOPAEDIC AND OCCUPATIONAL MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 67250 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685067250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023288833 | ||||||||
| FaxNumber: | 4023282921 | ||||||||
| Practice Location | |||||||||
| Address1: | 8207 NORTHWOODS DR | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685052093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024660555 | ||||||||
| FaxNumber: | 4024880743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 05/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | BOZARTH | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4024660555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 10025496100 | 05 | NE | MEDICAID | 612249700 | 01 | DOL ACS WORKERS COMP | OTHER |