Provider Demographics
NPI:1417958836
Name:BOESCH, RONNIE J (DC)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:J
Last Name:BOESCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:RON
Other - Middle Name:
Other - Last Name:BOESCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1000 BRADY ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-5214
Mailing Address - Country:US
Mailing Address - Phone:563-884-5567
Mailing Address - Fax:563-884-5740
Practice Address - Street 1:1000 BRADY ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-5214
Practice Address - Country:US
Practice Address - Phone:563-884-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2709111N00000X
TN1188111N00000X
IAAO5801111N00000X
MO1999140067111NN0400X
IL38009511111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA07860OtherBLUE CROSS BLUE SHIELD
MOU40236Medicare UPIN
IAI17265Medicare ID - Type Unspecified
IA07860OtherBLUE CROSS BLUE SHIELD