Provider Demographics
NPI:1407852064
Name:BOGGESS, BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:BOGGESS
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 1:3570 SHATTUCK RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-3153
Mailing Address - Country:US
Mailing Address - Phone:989-792-5353
Mailing Address - Fax:989-792-3033
Practice Address - Street 1:3570 SHATTUCK RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3153
Practice Address - Country:US
Practice Address - Phone:989-792-5353
Practice Address - Fax:989-792-3033
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBB050524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3208531Medicaid
MI0M20010002Medicare PIN
MIA78620Medicare UPIN