Basic Information
| Provider Information | |||||||||
| NPI: | 1093278152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGUSZ SHAND | ||||||||
| FirstName: | JAIMEE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000 LB#7550 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191953709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 206 BELLEVILLE AVE STE 204B | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070033589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737430202 | ||||||||
| FaxNumber: | 9737430777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2019 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NJ | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 25MB11519600 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.