Basic Information
| Provider Information | |||||||||
| NPI: | 1760781900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOETTCHER | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | DEPT OF ANESTHESIOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056104 | ||||||||
| FaxNumber: | 4148055195 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | DEPT OF ANESTHESIOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056104 | ||||||||
| FaxNumber: | 4148055195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2011 | ||||||||
| LastUpdateDate: | 07/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 58704 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1760781900 | 05 | WI | MEDICAID |