Provider Demographics
NPI:1902236417
Name:SUSAN BOGRAD
Entity Type:Organization
Organization Name:SUSAN BOGRAD
Other - Org Name:FULL NAME SUSAN BEAUSOLEIL BOGRAD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-320-1968
Mailing Address - Street 1:3300 E. 1ST AVENUE
Mailing Address - Street 2:SUITE 590
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-5818
Mailing Address - Country:US
Mailing Address - Phone:303-320-1968
Mailing Address - Fax:303-322-2155
Practice Address - Street 1:3300 E. 1ST AVENUE
Practice Address - Street 2:SUITE 590
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5818
Practice Address - Country:US
Practice Address - Phone:303-320-1968
Practice Address - Fax:303-322-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO343632084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E15038Medicare UPIN