Basic Information
| Provider Information | |||||||||
| NPI: | 1992725683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSCO | ||||||||
| FirstName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 WOODLAND ST | ||||||||
| Address2: | SUITE 23 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061052372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605222251 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 027419 | CT | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 001274191 | 05 | CT | MEDICAID |