MEDICARE: DR. BORIS V BOGOMILOV 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	207RC0001X	Clinical Cardiac Electrophysiology Physician	E4311	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	E4311	OTHER	AR	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5020011800	OTHER	AR	QUALCHOICE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	7934401	OTHER	AR	AETNA
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790749638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BORIS V BOGOMILOV MD

Provider Business Mailing Address
First Line	:	3211 N NORTHHILLS BLVD
Second Line	:	SUITE 110
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-4007
Country	:	US
Telephone Number	:	479-571-4338
Fax Number	:	479-571-4015

Provider Business Practice Location Address
First Line	:	3211 N NORTHHILLS BLVD
Second Line	:	SUITE 110
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-4007
Country	:	US
Telephone Number	:	479-571-4338
Fax Number	:	479-571-4015

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

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	03/07/2023

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Directions to “ DR. BORIS V BOGOMILOV MD” Practice Location

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