Provider Demographics
NPI:1619933538
Name:BOEHME, KEVIN G (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:G
Last Name:BOEHME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:EIGHTY FOUR
Mailing Address - State:PA
Mailing Address - Zip Code:15330-0173
Mailing Address - Country:US
Mailing Address - Phone:724-228-2488
Mailing Address - Fax:724-228-5592
Practice Address - Street 1:845 ROUTE 519
Practice Address - Street 2:
Practice Address - City:EIGHTY FOUR
Practice Address - State:PA
Practice Address - Zip Code:15330-2149
Practice Address - Country:US
Practice Address - Phone:724-228-2488
Practice Address - Fax:724-228-5592
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044666L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012804820002Medicaid
PABO715385Medicare PIN
PA0012804820002Medicaid