1487869830 NPI number — REGINA MARIA CUDEMO BOGLE MD

Table of content: REGINA MARIA CUDEMO BOGLE MD (NPI 1487869830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487869830 NPI number — REGINA MARIA CUDEMO BOGLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGLE
Provider First Name:
REGINA
Provider Middle Name:
MARIA CUDEMO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMOCK
Provider Other First Name:
REGINA
Provider Other Middle Name:
CUDEMO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487869830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618 FOURTH AVE
Provider Second Line Business Mailing Address:
# 206
Provider Business Mailing Address City Name:
BETHLEHEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-867-1200
Provider Business Mailing Address Fax Number:
610-867-1200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 FOURTH AVE
Provider Second Line Business Practice Location Address:
# 206
Provider Business Practice Location Address City Name:
BETHLEHEM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-867-1200
Provider Business Practice Location Address Fax Number:
610-867-1200
Provider Enumeration Date:
05/11/2007

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: 2084P0800X , with the licence number:  MD025310E , 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: 01092150 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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