Provider Demographics
NPI:1619095643
Name:BOHLEN, JOSEPH GLENN (MD PHD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:GLENN
Last Name:BOHLEN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 SPRING MILL DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6599
Mailing Address - Country:US
Mailing Address - Phone:217-546-3100
Mailing Address - Fax:217-546-3284
Practice Address - Street 1:3001 SPRING MILL DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6599
Practice Address - Country:US
Practice Address - Phone:217-546-3100
Practice Address - Fax:217-546-3284
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
08400618OtherBCBS
C49051Medicare UPIN
289560Medicare ID - Type Unspecified