Provider Demographics
NPI:1952485385
Name:THE WALTER E. BOEHM BIRTH DEFECTS CENTER, INC
Entity Type:Organization
Organization Name:THE WALTER E. BOEHM BIRTH DEFECTS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARREE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-778-2222
Mailing Address - Street 1:975 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2103
Mailing Address - Country:US
Mailing Address - Phone:423-778-2222
Mailing Address - Fax:423-778-6191
Practice Address - Street 1:910 BLACKFORD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1405
Practice Address - Country:US
Practice Address - Phone:423-778-2222
Practice Address - Fax:423-778-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4094742OtherBCBS OF TENNESSEE
NC5903251Medicaid
NC5903251Medicaid