1003085630 NPI number — PETER SHELBY BOGARD DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003085630 NPI number — PETER SHELBY BOGARD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER SHELBY BOGARD DO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1003085630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 SW RAMSEY
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
GRANTS PASS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97527-5788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-471-4930
Provider Business Mailing Address Fax Number:
541-471-1331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 SW RAMSEY
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97527-5788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-471-4930
Provider Business Practice Location Address Fax Number:
541-471-1331
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOGARD
Authorized Official First Name:
PETER
Authorized Official Middle Name:
SHELBY
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
541-471-4930

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X , with the licence number:  DO18557 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 058748 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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