MEDICARE: ROBERT BRADLEY BOUGHAN MD

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	208000000X	Pediatrics Physician	D0069537	MD
2	207R00000X	Internal Medicine Physician	D0069537	MD

General Provider Information

NPI Number	:	1770608721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT BRADLEY BOUGHAN MD

Provider Business Mailing Address
First Line	:	11121 YORK RD
Second Line	:
City	:	HUNT VALLEY
State	:	MD
Zip	:	21030-2006
Country	:	US
Telephone Number	:	410-628-0026
Fax Number	:	410-667-6834

Provider Business Practice Location Address
First Line	:	1734 YORK RD
Second Line	:
City	:	LUTHERVILLE
State	:	MD
Zip	:	21093-5606
Country	:	US
Telephone Number	:	410-252-2273
Fax Number	:

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	11/15/2024

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