Provider Demographics
NPI:1417973470
Name:BOGACZ, KATHLEEN PATT (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:PATT
Last Name:BOGACZ
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:390 S MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1767
Practice Address - Country:US
Practice Address - Phone:540-484-4800
Practice Address - Fax:540-484-4847
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-08-16
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Provider Licenses
StateLicense IDTaxonomies
IL036069602207R00000X
VA0101258121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL756590Medicare UPIN