Provider Demographics
NPI:1083882674
Name:STEPHEN P. BOGHOSSIAN, M.D., P.C.
Entity Type:Organization
Organization Name:STEPHEN P. BOGHOSSIAN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOGHOSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-834-7590
Mailing Address - Street 1:PO BOX 6851
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-6851
Mailing Address - Country:US
Mailing Address - Phone:630-834-7590
Mailing Address - Fax:630-516-9123
Practice Address - Street 1:1200 S YORK RD
Practice Address - Street 2:SUITE 4240
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5626
Practice Address - Country:US
Practice Address - Phone:630-834-7590
Practice Address - Fax:630-516-9123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02226004OtherBLUE CROSS
IL17-11003OtherUNITED HEALTHCARE
IL585990Medicare PIN
IL17-11003OtherUNITED HEALTHCARE