Provider Demographics
NPI:1891022596
Name:BOB E COGBURN MD PA
Entity Type:Organization
Organization Name:BOB E COGBURN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTICING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:E
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA, DBA
Authorized Official - Phone:870-425-5354
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654
Mailing Address - Country:US
Mailing Address - Phone:870-425-5354
Mailing Address - Fax:870-425-9656
Practice Address - Street 1:899 BURNETT DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-425-5354
Practice Address - Fax:870-425-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-4698207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113246001Medicaid
ARD80350Medicare UPIN
AR51097Medicare PIN