Provider Demographics
NPI:1255095105
Name:CEREBRAL MEDICAL GROUP, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CEREBRAL MEDICAL GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-489-9369
Mailing Address - Street 1:2093 PHILADELPHIA PIKE # 9898
Mailing Address - Street 2:
Mailing Address - City:CLAYMONT
Mailing Address - State:DE
Mailing Address - Zip Code:19703-2424
Mailing Address - Country:US
Mailing Address - Phone:415-403-2156
Mailing Address - Fax:415-651-3458
Practice Address - Street 1:8585 OLD DAIRY RD STE 208
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8094
Practice Address - Country:US
Practice Address - Phone:415-403-2156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-27
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty