Provider Demographics
NPI:1053375386
Name:BOGGS, BRUCE D (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:BOGGS
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 1:124 OLD GRAY STATION RD STE 1
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-3434
Mailing Address - Country:US
Mailing Address - Phone:423-477-0600
Mailing Address - Fax:423-477-0611
Practice Address - Street 1:124 OLD GRAY STATION RD STE 1
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-3434
Practice Address - Country:US
Practice Address - Phone:423-477-0600
Practice Address - Fax:423-477-0611
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD39382207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNBLUE CROSS BLUE SHIEOther4109177
TNP00339307Medicare PIN
I26255Medicare UPIN
TN33280601Medicare PIN
TNBLUE CROSS BLUE SHIEOther4109177
TNP00455108Medicare PIN