Provider Demographics
NPI:1972708162
Name:MARY ROSE BOEHM MD PA
Entity Type:Organization
Organization Name:MARY ROSE BOEHM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-242-1430
Mailing Address - Street 1:614 E HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3164
Mailing Address - Country:US
Mailing Address - Phone:352-242-1430
Mailing Address - Fax:352-242-1452
Practice Address - Street 1:200 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2582
Practice Address - Country:US
Practice Address - Phone:352-242-1430
Practice Address - Fax:352-242-1452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88288261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81213ZMedicare ID - Type Unspecified
FLI03579Medicare UPIN