Basic Information
| Provider Information | |||||||||
| NPI: | 1245227800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOEHME | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17809 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322457809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042494456 | ||||||||
| FaxNumber: | 9042497703 | ||||||||
| Practice Location | |||||||||
| Address1: | 1361 13TH AVE S | ||||||||
| Address2: | STE-170A | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042494456 | ||||||||
| FaxNumber: | 9042497703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 12/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME62533 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P00240372 | 01 | FL | RAILROAD MEDICARE | OTHER | 372291100 | 05 | FL | MEDICAID | 212248 | 01 | FL | AVMED | OTHER | 18695 | 01 | FL | FLORIDA BCBS | OTHER | P00647889 | 01 | FL | RAILROAD MEDICARE | OTHER |