Provider Demographics
NPI:1740219955
Name:BOGUCKI, ALFRED R (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:R
Last Name:BOGUCKI
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:P. O. BOX 8500 - 6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-6335
Mailing Address - Country:US
Mailing Address - Phone:215-807-8000
Mailing Address - Fax:215-612-9220
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:SUITE 211
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1445
Practice Address - Country:US
Practice Address - Phone:215-824-4559
Practice Address - Fax:215-612-9220
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042361E2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA020030561OtherRAILROAD MEDICARE
PA065584000OtherKEYSTONE IBC
PA1105258OtherCIGNA
PA746506OtherHIGHMARK BLUE SHIELD
PA746506OtherPERSONAL CHOIC E
PA20045179OtherAMERIHEALTH
PA3658357OtherAETNA HMO
PA0014120170011Medicaid
PA01412017-02OtherAMERICHOICE
PA30017961OtherKEYSTONE MERCY
PA1555030OtherUNITED HEALTHCARE
PA34799OtherHEALTH PARTNERS
PAPA0025546OtherTRICARE
PA746506OtherPERSONAL CHOIC E
PA746506RLTMedicare PIN