Basic Information
| Provider Information | |||||||||
| NPI: | 1427073873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGGESS | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 453 MONTE KARLO RD | ||||||||
| Address2: | |||||||||
| City: | MARBLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163341315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147823274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 FAIRFIELD DR | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163462130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146767600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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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 | 207P00000X | OS-010851-L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 58-000326 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0019090460005 | 05 | PA | MEDICAID | 0019090460004 | 05 | PA | MEDICAID | 0019090460006 | 05 | PA | MEDICAID |