Basic Information
| Provider Information | |||||||||
| NPI: | 1134127137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGIN | ||||||||
| FirstName: | FREDERICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 ASYLUM AVE | ||||||||
| Address2: | SUITE 2109A | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607146581 | ||||||||
| FaxNumber: | 8607148311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 ASYLUM AVE | ||||||||
| Address2: | SUITE 1026 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607144332 | ||||||||
| FaxNumber: | 8607148054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 02/24/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 019455 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 001194555 | 05 | CT | MEDICAID |