Provider Demographics
NPI:1518047471
Name:BOGUE, BRENDA ANN
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:ANN
Last Name:BOGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 ARDMORE CT
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-3630
Mailing Address - Country:US
Mailing Address - Phone:847-534-0892
Mailing Address - Fax:630-237-4454
Practice Address - Street 1:1161 ARDMORE CT
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-3630
Practice Address - Country:US
Practice Address - Phone:847-534-0892
Practice Address - Fax:630-237-4454
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0035640547OtherBLUE CROSS & BLUE SHIELD
ID210578Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
ILK13208Medicare ID - Type UnspecifiedMEMBER #