Provider Demographics
NPI:1174696736
Name:BOSE, BETHANAPALLI (CPO)
Entity type:Individual
Prefix:MR
First Name:BETHANAPALLI
Middle Name:
Last Name:BOSE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1-25 26TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3802
Mailing Address - Country:US
Mailing Address - Phone:718-680-0225
Mailing Address - Fax:201-796-5414
Practice Address - Street 1:6911 FORT HAMILTON PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-1101
Practice Address - Country:US
Practice Address - Phone:718-680-0225
Practice Address - Fax:201-796-5414
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1127940222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00835727Medicaid