Provider Demographics
NPI:1801289640
Name:G P BOYUM MD PLLC
Entity type:Organization
Organization Name:G P BOYUM MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:BOYUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-439-6845
Mailing Address - Street 1:2275 OVERLOOK CT N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-1566
Mailing Address - Country:US
Mailing Address - Phone:651-439-6845
Mailing Address - Fax:
Practice Address - Street 1:2275 OVERLOOK CT N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-1566
Practice Address - Country:US
Practice Address - Phone:651-439-6845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21557261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center