Healthcare Provider Details

I. General information

NPI: 1790977759
Provider Name (Legal Business Name): MARILYN JEAN BOEHM MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 E IVYBRIDGE DR 104
HUBERT NC
28539-4462
US

IV. Provider business mailing address

152 E IVYBRIDGE DR
HUBERT NC
28539-4462
US

V. Phone/Fax

Practice location:
  • Phone: 910-219-1339
  • Fax:
Mailing address:
  • Phone: 252-646-3338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31962
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: