Provider Demographics
NPI:1164400396
Name:BOHARSKI, MICHAEL GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:BOHARSKI
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 1:430 WINDWARD WAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2623
Mailing Address - Country:US
Mailing Address - Phone:406-752-5553
Mailing Address - Fax:406-752-5530
Practice Address - Street 1:430 WINDWARD WAY
Practice Address - Street 2:SUITE 203
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2619
Practice Address - Country:US
Practice Address - Phone:406-752-5553
Practice Address - Fax:406-752-5530
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5266174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT51571Medicaid
MTC64247Medicare UPIN