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NPI Code Detail

MEDICARE: BRIAN BOHOLST M.D.

MEDICARE: BRIAN BOHOLST M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine PhysicianIL

General Provider Information

NPI Number : 1235181959
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIAN BOHOLST M.D.
Provider Business Mailing Address
First Line : 3245 N HALSTED ST
Second Line :
City : CHICAGO
State : IL
Zip : 60657-3419
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3245 N HALSTED ST
Second Line :
City : CHICAGO
State : IL
Zip : 60657-3419
Country : US
Telephone Number : 312-926-3627
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/17/2006
Last Update Date : 07/08/2007

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Directions to “ BRIAN BOHOLST M.D.” Practice Location

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