Basic Information
| Provider Information | |||||||||
| NPI: | 1528050929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYUM | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5803 NEAL AVE N | ||||||||
| Address2: | |||||||||
| City: | OAK PARK HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550822177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Practice Location | |||||||||
| Address1: | 5803 NEAL AVE N | ||||||||
| Address2: | |||||||||
| City: | OAK PARK HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550822177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 11/15/2013 | ||||||||
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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 | 174400000X | 21557 | MN | Y | Other Service Providers | Specialist | 207XX0005X | 21557 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01218320 | 01 | MN | RR MEDICARE | OTHER |