=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184853558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL BOEHMER PINE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2009
-----------------------------------------------------
Last Update Date | 07/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 CHICAGO AVE STE 503
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-6515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-492-0162
-----------------------------------------------------
Fax | 847-492-8130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 CHICAGO AVE STE 503
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-6515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-492-0162
-----------------------------------------------------
Fax | 847-492-8130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 036075448
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------