Provider Demographics
NPI:1619939246
Name:HEADLAM, BO TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:TYLER
Last Name:HEADLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:68 S SERVICE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2354
Mailing Address - Country:US
Mailing Address - Phone:631-465-2094
Mailing Address - Fax:
Practice Address - Street 1:1735 27TH ST
Practice Address - Street 2:WALLER BUILDING, SUITE 302
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2677
Practice Address - Country:US
Practice Address - Phone:740-356-6808
Practice Address - Fax:740-356-6826
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE255882081P2900X, 208VP0000X, 208VP0014X
IL0361152632081P2900X, 208VP0014X
OH351202292081P2900X, 208VP0014X, 208VP0000X
NY2864982081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4632039OtherBCBS GROUP
IL356255Medicare Oscar/Certification
ILH86624Medicare UPIN
ILK44566Medicare PIN