MEDICARE: DR. KELLI LYNN BOGUE AU.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	1601000599	MI
2	231HA2400X	Assistive Technology Practitioner Audiologist	1601000599	MI
3	231HA2500X	Assistive Technology Supplier Audiologist	1601000599	MI
4	237600000X	Audiologist-Hearing Aid Fitter	1601000599	MI

General Provider Information

NPI Number	:	1154604064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLI LYNN BOGUE AU.D.

Provider Business Mailing Address
First Line	:	2027 4TH ST
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-4572
Country	:	US
Telephone Number	:	517-817-6017
Fax Number	:

Provider Business Practice Location Address
First Line	:	2027 4TH ST
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-4572
Country	:	US
Telephone Number	:	517-888-5055
Fax Number	:	517-888-5052

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2011
Last Update Date	:	05/02/2017

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