Healthcare Provider Details

I. General information

NPI: 1902064389
Provider Name (Legal Business Name): KEITH DANIEL BOHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 E 3RD ST
CHATTANOOGA TN
37403-2147
US

IV. Provider business mailing address

5301 VIRGINIA WAY STE 300
BRENTWOOD TN
37027-7542
US

V. Phone/Fax

Practice location:
  • Phone: 615-695-4977
  • Fax:
Mailing address:
  • Phone: 615-695-4977
  • Fax: 615-263-3348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number75748
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number56709
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4541
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35.094387
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number22066
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: