Provider Demographics
NPI:1265420301
Name:BOHLMAN, LYLE G (MD)
Entity type:Individual
Prefix:
First Name:LYLE
Middle Name:G
Last Name:BOHLMAN
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 1:195 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6701
Mailing Address - Country:US
Mailing Address - Phone:781-338-0500
Mailing Address - Fax:
Practice Address - Street 1:610 AIRPORT RD SW STE 100
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-4304
Practice Address - Country:US
Practice Address - Phone:256-429-4809
Practice Address - Fax:256-429-4163
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.37647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3002501Medicaid
A58200Medicare UPIN
MA3002501Medicaid