Provider Demographics
NPI:1881851491
Name:BOHANNON, SEAN BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:BRIAN
Last Name:BOHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36702-0570
Mailing Address - Country:US
Mailing Address - Phone:334-375-8007
Mailing Address - Fax:
Practice Address - Street 1:203 VAUGHAN MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6950
Practice Address - Country:US
Practice Address - Phone:334-375-8007
Practice Address - Fax:334-526-1849
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.30834207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL129899Medicaid
GA20208I3869Medicare PIN
AL102I084948Medicare PIN