Provider Demographics
NPI:1427073873
Name:BOGGESS, RANDY (DO)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BOGGESS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 MONTE KARLO RD
Mailing Address - Street 2:
Mailing Address - City:MARBLE
Mailing Address - State:PA
Mailing Address - Zip Code:16334-1315
Mailing Address - Country:US
Mailing Address - Phone:814-782-3274
Mailing Address - Fax:
Practice Address - Street 1:100 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346-2130
Practice Address - Country:US
Practice Address - Phone:814-676-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-010851-L207P00000X
OH58-000326207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019090460005Medicaid
PA0019090460004Medicaid
PA0019090460006Medicaid
PA0019090460005Medicaid
PA057641L5BMedicare PIN