MEDICARE: LARRY M BOEHLKE NP

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	363L00000X	Nurse Practitioner	209002685	IL

General Provider Information

NPI Number	:	1972575231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY M BOEHLKE NP

Provider Business Mailing Address
First Line	:	25068 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-0001
Country	:	US
Telephone Number	:	847-585-7000
Fax Number	:	847-240-0622

Provider Business Practice Location Address
First Line	:	676 N ST CLAIR
Second Line	:	STE 2140
City	:	CHICAGO
State	:	IL
Zip	:	60611
Country	:	US
Telephone Number	:	312-664-5400
Fax Number	:	312-664-5854

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	06/02/2010

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