1477540433 NPI number — JEFFREY DAVID BOEHME O.D.

Table of content: JEFFREY DAVID BOEHME O.D. (NPI 1477540433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477540433 NPI number — JEFFREY DAVID BOEHME O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOEHME
Provider First Name:
JEFFREY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477540433
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 HAYS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENETIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15367-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-941-3404
Provider Business Mailing Address Fax Number:
412-655-6513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2027 LEBANON CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MIFFLIN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15122-2461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-655-6444
Provider Business Practice Location Address Fax Number:
412-655-6513
Provider Enumeration Date:
10/04/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG000653 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410036489 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1725156 02 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".