Basic Information
| Provider Information | |||||||||
| NPI: | 1104881408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSSMAN | ||||||||
| FirstName: | OWEN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6255 SHERIDAN DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142214836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578666 | ||||||||
| FaxNumber: | 7168578944 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578625 | ||||||||
| FaxNumber: | 7162505961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 090635-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0001001840 | 01 | NY | UNIVERA | OTHER | 00481085 | 05 | NY | MEDICAID | 090635-4B | 01 | NY | WORKERS COMPENSATION | OTHER | 2800146 | 01 | NY | IHA | OTHER | 000502176001 | 01 | NY | HEALTH NOW | OTHER |