Basic Information
| Provider Information | |||||||||
| NPI: | 1831345362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOHM | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11725 N ILLINOIS ST. | ||||||||
| Address2: | SUITE 275 | ||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460323009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176882000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2008 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OT012164 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OS015141 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 02004091A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 201095720 | 05 | IN | MEDICAID |