Provider Demographics
NPI:1447279344
Name:BOOM, WILLEM H (MD)
Entity type:Individual
Prefix:
First Name:WILLEM
Middle Name:H
Last Name:BOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-057716207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0642326OtherAETNA
363372OtherWELLCARE
OH700006744OtherRAILROAD MEDICARE
000000539533OtherANTHEM
000000224351OtherUNISON
OH0728163Medicaid
OH746006OtherBUCKEYE
OHP00449264OtherRAILROAD MEDICARE
000000224351OtherUNISON
OH746006OtherBUCKEYE
OHP00449264OtherRAILROAD MEDICARE