Provider Demographics
NPI:1356321145
Name:BOGOSIAN, PAUL GEORGE (DC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:GEORGE
Last Name:BOGOSIAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 ANITA DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2807
Mailing Address - Country:US
Mailing Address - Phone:215-342-2225
Mailing Address - Fax:215-342-3232
Practice Address - Street 1:7715 WHITAKER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2854
Practice Address - Country:US
Practice Address - Phone:215-342-2225
Practice Address - Fax:215-342-3232
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002358L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0905356Medicaid
PA4338939OtherAETNA TRADITIONAL
PA088735OtherBLUE CROSS BLUE SHIELD
PA0061021000OtherKEYSTONE HEALTH PLAN EAST
PA94051OtherAETNA HMO
PA088735Medicare ID - Type UnspecifiedMEDICARE
PA0905356Medicaid