Provider Demographics
NPI:1699086074
Name:RICHARD C. BOUGHN, MD PC
Entity type:Organization
Organization Name:RICHARD C. BOUGHN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RIC HARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-769-7771
Mailing Address - Street 1:613 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1704
Mailing Address - Country:US
Mailing Address - Phone:503-769-7771
Mailing Address - Fax:503-769-4630
Practice Address - Street 1:613 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1704
Practice Address - Country:US
Practice Address - Phone:503-769-7771
Practice Address - Fax:503-769-4630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR072678Medicaid
OR072678Medicaid
C92253Medicare UPIN