Healthcare Provider Details

I. General information

NPI: 1023637477
Provider Name (Legal Business Name): JOSH BOHN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 PICKLE RD
OREGON OH
43616-4026
US

IV. Provider business mailing address

542 EAST ST
PEMBERVILLE OH
43450-9694
US

V. Phone/Fax

Practice location:
  • Phone: 419-693-0465
  • Fax:
Mailing address:
  • Phone: 419-376-7297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT004377
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: