Basic Information
| Provider Information | |||||||||
| NPI: | 1649266412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSO | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 AVERY ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044223904 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044242590 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35070251 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 15116 | WV | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0041118000 | 05 | WV | MEDICAID | 0784183 | 05 | OH | MEDICAID |