Provider Demographics
NPI:1679554380
Name:BOGART, LEE H (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:H
Last Name:BOGART
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 1:3998 RED LION RD
Mailing Address - Street 2:STE 130
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1443
Mailing Address - Country:US
Mailing Address - Phone:610-521-2010
Mailing Address - Fax:
Practice Address - Street 1:33 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2035
Practice Address - Country:US
Practice Address - Phone:610-521-2012
Practice Address - Fax:610-521-3753
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037855E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013009050001Medicaid
PAB0677166Medicare ID - Type Unspecified
PA0013009050001Medicaid
1304740002Medicare NSC