Provider Demographics
NPI:1750300141
Name:BOEHM, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:BOEHM
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 1:300 W HOSPITAL RD
Mailing Address - Street 2:MEB SECTION
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-9136
Mailing Address - Fax:706-787-9136
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:MEB SECTION
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-9136
Practice Address - Fax:706-787-9136
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55585207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271186900Medicaid
FL34-1371375OtherFEI
P00699936OtherRAILROAD MEDICARE
P00830193OtherRAILROAD MEDICARE ATTACHED TO GRP DQ3034
FL09314Medicare PIN
P00830193OtherRAILROAD MEDICARE ATTACHED TO GRP DQ3034
FLA15176Medicare UPIN