Provider Demographics
NPI:1154989929
Name:BOOHER, MATTHEW STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:BOOHER
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 PILGRIM BLVD
Practice Address - Street 2:
Practice Address - City:HARTFORD CITY
Practice Address - State:IN
Practice Address - Zip Code:47348-1382
Practice Address - Country:US
Practice Address - Phone:765-348-0300
Practice Address - Fax:317-963-5492
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351045260207P00000X
IN01087572A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine