Provider Demographics
NPI:1104052844
Name:KATHRYN E. BOEHM, MD, LLC
Entity type:Organization
Organization Name:KATHRYN E. BOEHM, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:419-724-6888
Mailing Address - Street 1:3454 OAK ALLEY CT
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1306
Mailing Address - Country:US
Mailing Address - Phone:419-724-6888
Mailing Address - Fax:419-724-6893
Practice Address - Street 1:3454 OAK ALLEY CT
Practice Address - Street 2:SUITE 210
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1306
Practice Address - Country:US
Practice Address - Phone:419-724-6888
Practice Address - Fax:419-724-6893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35056573B261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0744430Medicaid
9347012OtherMEDICARE PTAN GROUP #
OHKA9347011OtherMEDICARE PTAN GROUP #
OH3159862OtherMEDICAID GROUP NUMBER