Provider Demographics
NPI:1225092554
Name:BOEHM, BRADLEY ALLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALLEN
Last Name:BOEHM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 US 23 NORTH
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707
Mailing Address - Country:US
Mailing Address - Phone:989-354-0607
Mailing Address - Fax:989-356-6710
Practice Address - Street 1:1065 US 23 NORTH
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707
Practice Address - Country:US
Practice Address - Phone:989-354-0607
Practice Address - Fax:989-356-6710
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBB012930208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3438729Medicaid
MI0M17350Medicare PIN
G16756Medicare UPIN