Healthcare Provider Details

I. General information

NPI: 1831299148
Provider Name (Legal Business Name): CHARLES R BOGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 CHANNING WAY SUITE 116
IDAHO FALLS ID
83404-7531
US

IV. Provider business mailing address

1452 THREE FOUNTAINS DR
IDAHO FALLS ID
83404-5641
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4567
  • Fax:
Mailing address:
  • Phone: 208-535-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM2659
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: