Healthcare Provider Details

I. General information

NPI: 1568998599
Provider Name (Legal Business Name): BENJAMIN K BOEHME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HAZEL LN STE 201
SEWICKLEY PA
15143-1249
US

IV. Provider business mailing address

100 HAZEL LN STE 201
SEWICKLEY PA
15143-1249
US

V. Phone/Fax

Practice location:
  • Phone: 412-749-6806
  • Fax:
Mailing address:
  • Phone: 412-749-6806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT017858
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS020612
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: