Provider Demographics
NPI:1124376892
Name:BOTHFELD, NATHANIEL S (PT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:S
Last Name:BOTHFELD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:1650 LEE LN
Practice Address - Street 2:OCCUPATION HEALTH PORTS & FAMILY MEDICINE CENTER
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3935
Practice Address - Country:US
Practice Address - Phone:608-362-0211
Practice Address - Fax:608-364-4670
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9109225100000X
WI12179-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9109OtherMINNESOTA BOARD OF PHYSICALTHERAPY