Provider Demographics
NPI:1619298213
Name:BOEHM, MARCUS (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:
Last Name:BOEHM
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N PROSPECT ST APT 137
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 N PROSPECT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1966
Practice Address - Country:US
Practice Address - Phone:315-866-6728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000002767237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist