Provider Demographics
NPI:1912973249
Name:BOGGESS, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BOGGESS
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 1:213 OVERLOOK CIR STE B3
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3241
Mailing Address - Country:US
Mailing Address - Phone:615-942-8016
Mailing Address - Fax:615-739-5376
Practice Address - Street 1:213 OVERLOOK CIR STE B3
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3241
Practice Address - Country:US
Practice Address - Phone:615-942-8016
Practice Address - Fax:615-739-5376
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2015-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31982174400000X
TN44489207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64007750Medicaid
TNQ017030Medicaid
KY64007750Medicaid
KY1834801Medicare ID - Type Unspecified