Healthcare Provider Details

I. General information

NPI: 1275510356
Provider Name (Legal Business Name): RONALD G. BOOGAARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 NORTHWEST DR
LEBANON PA
17042-8915
US

IV. Provider business mailing address

130 NORTHWEST DR
LEBANON PA
17042-8915
US

V. Phone/Fax

Practice location:
  • Phone: 717-274-5902
  • Fax:
Mailing address:
  • Phone: 717-274-5902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD031413E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD031413E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: