MEDICARE: DR. KATHLEEN SUE BOHANON MD

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
1	2080N0001X	Neonatal-Perinatal Medicine Physician	38505	CO
2	2080N0001X	Neonatal-Perinatal Medicine Physician	35042157B	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669479705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN SUE BOHANON MD

Provider Business Mailing Address
First Line	:	4090 STONEBRIDGE PT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-4704
Country	:	US
Telephone Number	:	719-685-0585
Fax Number	:

Provider Business Practice Location Address
First Line	:	4090 STONEBRIDGE PT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-4704
Country	:	US
Telephone Number	:	719-685-0585
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	07/08/2007

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