Basic Information
Provider Information | |||||||||
NPI: | 1649437468 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BHOGTE | ||||||||
FirstName: | ERVIND | ||||||||
MiddleName: | SRIRAM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 HOSPITAL RD | ||||||||
Address2: |   | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104144791 | ||||||||
FaxNumber: | 4104144558 | ||||||||
Practice Location | |||||||||
Address1: | 110 HOSPITAL RD | ||||||||
Address2: | SUITE 210 | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104149017 | ||||||||
FaxNumber: | 4104149019 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2008 | ||||||||
LastUpdateDate: | 09/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD038703 | DC | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | MD038703 | DC | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | D0073682 | MD | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 208600000X | D0073682 | MD | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 421294100 | 05 | MD |   | MEDICAID |