Provider Demographics
NPI:1265544308
Name:MOGERMAN, RICHARD LEE (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:MOGERMAN
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 1:9991 COOPER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FREE SOIL
Mailing Address - State:MI
Mailing Address - Zip Code:49411-9717
Mailing Address - Country:US
Mailing Address - Phone:231-723-0752
Mailing Address - Fax:
Practice Address - Street 1:9991 COOPER CREEK RD
Practice Address - Street 2:
Practice Address - City:FREE SOIL
Practice Address - State:MI
Practice Address - Zip Code:49411-9717
Practice Address - Country:US
Practice Address - Phone:231-723-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-04-07
Deactivation Date:2017-03-08
Deactivation Code:
Reactivation Date:2021-04-07
Provider Licenses
StateLicense IDTaxonomies
MI4301045763207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2869366Medicaid
0535763OtherBCBS
B41122Medicare UPIN
B41122Medicare UPIN