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General NPI Number Information
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NPI Number | 1619939246
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Entity Type | Individual
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Provider Name | BO TYLER HEADLAM M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/06/2006
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Last Update Date | 02/19/2025
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Provider Practice Location Address
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Address Line | 1735 27TH ST WALLER BUILDING, SUITE 302
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City | PORTSMOUTH
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State | OH
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Zip | 45662-2677
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Country | US
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Telephone | 740-356-6808
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Fax | 740-356-6826
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Provider Business Mailing Address
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Address Line | 68 S SERVICE RD SUITE 100
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City | MELVILLE
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State | NY
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Zip | 11747-2354
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Country | US
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Telephone | 631-465-2094
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 25588
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 036115263
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 25588
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License Number State | NE
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Taxonomy #4
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 25588
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License Number State | NE
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Taxonomy #5
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 036115263
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License Number State | IL
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Taxonomy #6
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 35120229
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License Number State | OH
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Taxonomy #7
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 35120229
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License Number State | OH
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Taxonomy #8
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 35120229
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License Number State | OH
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Taxonomy #9
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 286498
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License Number State | NY
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Taxonomy #10
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 286498
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License Number State | NY
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