Healthcare Provider Details

I. General information

NPI: 1972678894
Provider Name (Legal Business Name): GREGORY X BOEHM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26777 LORAIN RD SUITE 716
NORTH OLMSTED OH
44070-3200
US

IV. Provider business mailing address

26777 LORAIN RD SUITE 716
NORTH OLMSTED OH
44070-3200
US

V. Phone/Fax

Practice location:
  • Phone: 440-777-9200
  • Fax: 440-777-9288
Mailing address:
  • Phone: 440-777-9200
  • Fax: 440-777-9288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35-04-1394-B
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number35-04-1394-B
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35-04-1394-B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: