Provider Demographics
NPI:1790788248
Name:BOEHM, KATHRYN ELAINE (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ELAINE
Last Name:BOEHM
Suffix:
Gender:F
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 BRIDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1003
Mailing Address - Country:US
Mailing Address - Phone:419-509-6798
Mailing Address - Fax:866-888-0321
Practice Address - Street 1:424 W WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-5027
Practice Address - Country:US
Practice Address - Phone:419-509-6798
Practice Address - Fax:866-888-0321
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-6573-B2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2827491-180Medicaid
OH3159862OtherMEDICAID GROUP NUMBER
OH0744430Medicaid
OH35-05-6573-BOtherLICENSE
OH35-05-6573-BOtherLICENSE
OH35-05-6573-BOtherLICENSE
0712745Medicare PIN
OH35-05-6573-BOtherLICENSE
MI2827491-180Medicaid
OH0744430Medicaid