Provider Demographics
NPI:1851917447
Name:BOUM, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BOUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 ROUND TOP RD APT B
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-2526
Mailing Address - Country:US
Mailing Address - Phone:513-580-9678
Mailing Address - Fax:
Practice Address - Street 1:9330 ROUND TOP RD APT B
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45251-2526
Practice Address - Country:US
Practice Address - Phone:513-580-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide