Provider Demographics
NPI:1568998599
Name:BOEHME, BENJAMIN K
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:K
Last Name:BOEHME
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 1:100 HAZEL LN STE 201
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-1249
Mailing Address - Country:US
Mailing Address - Phone:412-749-6806
Mailing Address - Fax:
Practice Address - Street 1:100 HAZEL LN STE 201
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-1249
Practice Address - Country:US
Practice Address - Phone:412-749-6806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS020612207Q00000X
PAOT017858390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program