Basic Information
Provider Information | |||||||||
NPI: | 1730152034 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOETTICHER | ||||||||
FirstName: | ABIGAIL | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BENTCH | ||||||||
OtherFirstName: | ABIGAIL | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2828 CHICAGO AVE SOUTH | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128791000 | ||||||||
FaxNumber: | 6128799116 | ||||||||
Practice Location | |||||||||
Address1: | 2828 CHICAGO AVE SOUTH | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128791000 | ||||||||
FaxNumber: | 6128799116 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2006 | ||||||||
LastUpdateDate: | 10/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 46169 | MN | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0400X | 46169 | MN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 871425800 | 05 | MN |   | MEDICAID |