Provider Demographics
NPI:1144344391
Name:ROBERT W. BOHUS, M.D., F.A.C.S.
Entity type:Organization
Organization Name:ROBERT W. BOHUS, M.D., F.A.C.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOHUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:208-233-3355
Mailing Address - Street 1:500 S 11TH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4879
Mailing Address - Country:US
Mailing Address - Phone:208-233-3355
Mailing Address - Fax:208-232-6118
Practice Address - Street 1:500 S 11TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4879
Practice Address - Country:US
Practice Address - Phone:208-233-3355
Practice Address - Fax:208-232-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6361208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1368125Medicare ID - Type UnspecifiedMDCR GROUP NUMBER
ID1129620Medicare ID - Type UnspecifiedMDCR INDIVIDUAL PROV #
IDA73069Medicare UPIN