=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720742745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEREBRAL MEDICAL GROUP, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2021
-----------------------------------------------------
Last Update Date | 02/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 SW 7TH ST # 3C
-----------------------------------------------------
City | TOPEKA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66603-3858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-830-5946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2093 PHILADELPHIA PIKE # 9898
-----------------------------------------------------
City | CLAYMONT
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19703-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-830-5946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL BOGGS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 415-830-5946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------