Basic Information
| Provider Information | |||||||||
| NPI: | 1598838278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOHANNON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 HARTFORD ST | ||||||||
| Address2: | |||||||||
| City: | HOULTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075322900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 HARTFORD ST | ||||||||
| Address2: | |||||||||
| City: | HOULTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047301891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075322900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 05/24/2017 | ||||||||
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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 | 207Q00000X | ME0045018 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | MD19119 | ME | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME45018 | 01 | FL | STATE MEDICAL LICENSE | OTHER | 048103300 | 05 | FL | MEDICAID |