Basic Information
| Provider Information | |||||||||
| NPI: | 1831142413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOETTCHER | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | MELVIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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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 | 207Q00000X | 28490 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 340G8BO | 01 | MN | BLUE CROSS CLINICS | OTHER | 01-21114 | 01 | MN | MEDICA ISLE CLINIC | OTHER | 01-21117 | 01 | MN | MEDICA HILLMAN CLINIC | OTHER | 340G9BO | 01 | MN | BLUE CROSS HOSPITAL | OTHER | NA9090253011 | 01 | MN | PREFERRED ONE | OTHER | 109558 | 01 | MN | UCARE | OTHER | 01-21010 | 01 | MN | MEDICA ONAMIA | OTHER | 206780300 | 05 | MN | MEDICAID |