Healthcare Provider Details

I. General information

NPI: 1902891484
Provider Name (Legal Business Name): BERNARD R BOEHMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 ALBION AVE
BURLEY ID
83318-1817
US

IV. Provider business mailing address

1335 ALBION AVE
BURLEY ID
83318-1817
US

V. Phone/Fax

Practice location:
  • Phone: 208-878-2271
  • Fax: 208-878-2270
Mailing address:
  • Phone: 208-878-2271
  • Fax: 208-878-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6848
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: