Basic Information
Provider Information | |||||||||
NPI: | 1942654165 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOSCO | ||||||||
FirstName: | ANNALIESE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7261 MERCY RD | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681242311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023986248 | ||||||||
FaxNumber: | 4028298513 | ||||||||
Practice Location | |||||||||
Address1: | 200 HAWKINS DRIVE | ||||||||
Address2: | DEPARTMENT OF NEUROLOGY-2 RCP UI HOSPITALS AND CLINICS | ||||||||
City: | IOWA CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 52242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193568752 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2016 | ||||||||
LastUpdateDate: | 06/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 32706 | NE | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.