Provider Demographics
NPI:1487666947
Name:BOETTCHER, BRADLEY S (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:BOETTCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5181
Mailing Address - Country:US
Mailing Address - Phone:715-423-0122
Mailing Address - Fax:
Practice Address - Street 1:2031 PEACH ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5181
Practice Address - Country:US
Practice Address - Phone:715-423-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31647300Medicaid
WI000837005Medicare ID - Type Unspecified
WI000203003Medicare Oscar/Certification
WIE59973Medicare UPIN