Provider Demographics
NPI:1073043030
Name:KEMP BOHAN, PHILLIP MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:KEMP BOHAN
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 1:3551 ROGER BROOKE DRIVE
Mailing Address - Street 2:MCHE-QD
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4505
Mailing Address - Country:US
Mailing Address - Phone:210-916-2460
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DRIVE, MCHE-QD
Practice Address - Street 2:BROOKE ARMY MEDICAL CENTER
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4505
Practice Address - Country:US
Practice Address - Phone:210-916-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101266840208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program