Basic Information
| Provider Information | |||||||||
| NPI: | 1477599074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOHAC | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19070 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543079070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 ASH STREET | ||||||||
| Address2: | |||||||||
| City: | SPOONER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548011903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156352151 | ||||||||
| FaxNumber: | 7158395176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25128 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30518600 | 05 | WI | MEDICAID |