Individual
DR. BO TYLER HEADLAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1735 27TH ST, WALLER BUILDING, SUITE 302, PORTSMOUTH, OH 45662-2677
(740) 356-6808
(740) 356-6826
Mailing address
68 S SERVICE RD, SUITE 100, MELVILLE, NY 11747-2354
(631) 465-2094
Taxonomy
Speciality
Code
Description
License number
State
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
036115263
IL
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
25588
NE
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
286498
NY
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
35120229
OH
208VP0000X
Pain Medicine Physician
25588
NE
208VP0000X
Pain Medicine Physician
35120229
OH
208VP0014X
Interventional Pain Medicine Physician
036115263
IL
208VP0014X
Interventional Pain Medicine Physician
25588
NE
208VP0014X
Interventional Pain Medicine Physician
Primary
286498
NY
208VP0014X
Interventional Pain Medicine Physician
35120229
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4632039
BCBS GROUP
IL
Enumeration date
04/06/2006
Last updated
02/19/2025
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