Healthcare Provider Details

I. General information

NPI: 1780039735
Provider Name (Legal Business Name): KEVIN BOGDANSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

1370 JOHNSON AVE STE 102
BRIDGEPORT WV
26330-1492
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4800
  • Fax:
Mailing address:
  • Phone: 681-342-3457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28967
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: