1740219955 NPI number — ALFRED R. BOGUCKI M.D.

Table of content: KELSEY MOORE (NPI 1417544081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740219955 NPI number — ALFRED R. BOGUCKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGUCKI
Provider First Name:
ALFRED
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740219955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P. O. BOX 8500 - 6335
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-6335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-807-8000
Provider Business Mailing Address Fax Number:
215-612-9220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3998 RED LION RD
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19114-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-824-4559
Provider Business Practice Location Address Fax Number:
215-612-9220
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0127X , with the licence number:  MD042361E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 020030561 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 065584000 . This is a "KEYSTONE IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1105258 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 746506 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 746506 . This is a "PERSONAL CHOIC E" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20045179 . This is a "AMERIHEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3658357 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0014120170011 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01412017-02 . This is a "AMERICHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30017961 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1555030 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 34799 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PA0025546 . This is a "TRICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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