Healthcare Provider Details

I. General information

NPI: 1689639643
Provider Name (Legal Business Name): FRED EDWARD BOEHMKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 MAIN ST SUITE 8
WILLIAMSVILLE NY
14221-6046
US

IV. Provider business mailing address

8201 MAIN ST SUITE 8
WILLIAMSVILLE NY
14221-6046
US

V. Phone/Fax

Practice location:
  • Phone: 716-626-6626
  • Fax: 716-626-6646
Mailing address:
  • Phone: 716-626-6626
  • Fax: 716-626-6646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number130603
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: