Healthcare Provider Details

I. General information

NPI: 1053375386
Provider Name (Legal Business Name): BRUCE D BOGGS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 OLD GRAY STATION RD STE 1
GRAY TN
37615-3434
US

IV. Provider business mailing address

124 OLD GRAY STATION RD STE 1
GRAY TN
37615-3434
US

V. Phone/Fax

Practice location:
  • Phone: 423-477-0600
  • Fax: 423-477-0611
Mailing address:
  • Phone: 423-477-0600
  • Fax: 423-477-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD39382
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD39382
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: