Provider Demographics
NPI:1003085630
Name:PETER SHELBY BOGARD DO
Entity Type:Organization
Organization Name:PETER SHELBY BOGARD DO
Other - Org Name:BOGARD FAMILY AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:SHELBY
Authorized Official - Last Name:BOGARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-471-4930
Mailing Address - Street 1:700 SW RAMSEY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5788
Mailing Address - Country:US
Mailing Address - Phone:541-471-4930
Mailing Address - Fax:541-471-1331
Practice Address - Street 1:700 SW RAMSEY
Practice Address - Street 2:SUITE 104
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5788
Practice Address - Country:US
Practice Address - Phone:541-471-4930
Practice Address - Fax:541-471-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO18557207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR058748Medicaid
ORR112564Medicare PIN
ORF67383Medicare UPIN