=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174597702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY A BOHN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 295 MAPLE ST STE 200
-----------------------------------------------------
City | TAWAS CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48763-9352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-984-3788
-----------------------------------------------------
Fax | 989-984-3794
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 779
-----------------------------------------------------
City | TAWAS CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48764-0779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-362-9411
-----------------------------------------------------
Fax | 989-362-9925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036089196
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 29059
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------