Provider Demographics
NPI:1447565627
Name:B R BOEHMER MD PA
Entity Type:Organization
Organization Name:B R BOEHMER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOEHMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:208-878-2271
Mailing Address - Street 1:1335 ALBION AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1335 ALBION AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1817
Practice Address - Country:US
Practice Address - Phone:208-878-2271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6848261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002799800Medicaid
ID002799800Medicaid