Provider Demographics
NPI:1255513677
Name:MARTIN S. BOHM, D.O., PLLC
Entity type:Organization
Organization Name:MARTIN S. BOHM, D.O., PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BOHM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-776-1950
Mailing Address - Street 1:2802 MADISON SQUARE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-3387
Mailing Address - Country:US
Mailing Address - Phone:970-776-1950
Mailing Address - Fax:970-776-1954
Practice Address - Street 1:2802 MADISON SQUARE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3387
Practice Address - Country:US
Practice Address - Phone:970-776-1950
Practice Address - Fax:970-776-1954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44910OtherCOLORADO STATE LICENSE
CO70123012Medicaid
COC811228Medicare PIN
CO44910OtherCOLORADO STATE LICENSE
COH23735Medicare UPIN