Provider Demographics
NPI:1003844812
Name:BOGGAN, MICHAEL DAHYL (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAHYL
Last Name:BOGGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W STONE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-6027
Mailing Address - Country:US
Mailing Address - Phone:423-245-5197
Mailing Address - Fax:423-247-5254
Practice Address - Street 1:111 W STONE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6027
Practice Address - Country:US
Practice Address - Phone:423-247-5197
Practice Address - Fax:423-247-5254
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21139208D00000X
VA0101246769208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000908Medicaid
TN3057903Medicaid
KYP00262488Medicaid
VA010199743Medicaid
TN621112685OtherUNITED HEALTH CARE
KY65906208Medicaid
TNZ101OtherUNITED HEALTHCARE OF THE RIVER VALLEY
VAVAA101322Medicare PIN
TN621112685OtherUNITED HEALTH CARE
TND64913Medicare UPIN
TN1000908Medicaid
TN103I332924Medicare PIN
TN3287305Medicare PIN
TN3057903Medicare PIN
TNZ101OtherUNITED HEALTHCARE OF THE RIVER VALLEY
VAC05950Medicare PIN
VAV V3877AMedicare PIN
VAV V3877BMedicare PIN
TN103I933185Medicare PIN