Basic Information
| Provider Information | |||||||||
| NPI: | 1093787749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSE | ||||||||
| FirstName: | RAJ | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3709 N CAMPBELL AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857191563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208382138 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2404 E RIVER RD | ||||||||
| Address2: | BLD.2, STE 100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206964780 | ||||||||
| FaxNumber: | 5204081847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 27633 | AZ | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 515661 | 05 | AZ | MEDICAID | 330005254 | 01 | AZ | RR MEDICARE | OTHER | ZWCGCR | 01 | AZ | GROUP MEDICARE NUMBER | OTHER |