Provider Demographics
NPI:1649593773
Name:MICHAEL D BOEHM MD PA
Entity Type:Organization
Organization Name:MICHAEL D BOEHM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-752-4646
Mailing Address - Street 1:1601 W REYNOLDS ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4748
Mailing Address - Country:US
Mailing Address - Phone:813-752-4646
Mailing Address - Fax:813-752-5104
Practice Address - Street 1:1601 W REYNOLDS ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4748
Practice Address - Country:US
Practice Address - Phone:813-752-4646
Practice Address - Fax:813-752-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55585207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DQ3034OtherRAILROAD MEDICARE
FL271188500Medicaid
FLCY599AMedicare PIN