Provider Demographics
NPI:1407213796
Name:BOHANNAN, TOMMY
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:
Last Name:BOHANNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11417 N BOULDER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-1500
Mailing Address - Country:US
Mailing Address - Phone:309-678-8081
Mailing Address - Fax:
Practice Address - Street 1:11417 N BOULDER CREEK CT
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-1500
Practice Address - Country:US
Practice Address - Phone:309-678-8081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies