Basic Information
| Provider Information | |||||||||
| NPI: | 1275917064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSHARA | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ROSHDY | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W THOMAS RD STE 500 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064000 | ||||||||
| FaxNumber: | 6024066498 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD STE 850 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024061150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2015 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0001X | 4301504386 | MI | N | 207R00000X | 4301504386 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0001X | 65310 | AZ | N | 207RC0000X | 4301504386 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 65310 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 163453 | 05 | AZ | MEDICAID |