Basic Information
| Provider Information | |||||||||
| NPI: | 1194752402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSCO | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 809 | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070390809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003450064 | ||||||||
| FaxNumber: | 9732511109 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 S MANNING BLVD | ||||||||
| Address2: | @ ST. PETERS HOSPITAL ER DEPT. | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122081707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185251324 | ||||||||
| FaxNumber: | 5183834223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 12/16/2008 | ||||||||
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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 | 207P00000X | 170462-1 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01831121 | 05 | NY | MEDICAID |