Provider Demographics
NPI:1972575231
Name:BOEHLKE, LARRY M (NP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:BOEHLKE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25068 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-0001
Mailing Address - Country:US
Mailing Address - Phone:847-585-7000
Mailing Address - Fax:847-240-0622
Practice Address - Street 1:676 N ST CLAIR
Practice Address - Street 2:STE 2140
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-664-5400
Practice Address - Fax:312-664-5854
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002685363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00817006Medicare PIN
P08186Medicare UPIN
IL218740004Medicare PIN