Healthcare Provider Details

I. General information

NPI: 1144254046
Provider Name (Legal Business Name): BONNIE J OGDEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30795 23 MILE RD STE 201
CHESTERFIELD MI
48047-5721
US

IV. Provider business mailing address

133 S MAIN ST
MOUNT CLEMENS MI
48043-2308
US

V. Phone/Fax

Practice location:
  • Phone: 586-421-1600
  • Fax: 586-421-1800
Mailing address:
  • Phone: 586-329-1880
  • Fax: 586-231-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601003396
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: