Provider Demographics
NPI:1669457602
Name:CARMEN V BOGDAN MD PLLC
Entity Type:Organization
Organization Name:CARMEN V BOGDAN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:BOGDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-203-0917
Mailing Address - Street 1:3620 JOSHUA DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5267
Mailing Address - Country:US
Mailing Address - Phone:248-203-0917
Mailing Address - Fax:248-203-0924
Practice Address - Street 1:2191 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-3479
Practice Address - Country:US
Practice Address - Phone:248-724-1420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064314207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4726362Medicaid
G63069Medicare UPIN
MI0N98370Medicare PIN