Healthcare Provider Details

I. General information

NPI: 1740219955
Provider Name (Legal Business Name): ALFRED R. BOGUCKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 RED LION RD SUITE 211
PHILADELPHIA PA
19114-1445
US

IV. Provider business mailing address

P. O. BOX 8500 - 6335
PHILADELPHIA PA
19178-6335
US

V. Phone/Fax

Practice location:
  • Phone: 215-824-4559
  • Fax: 215-612-9220
Mailing address:
  • Phone: 215-807-8000
  • Fax: 215-612-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD042361E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: