Provider Demographics
NPI:1760781900
Name:BOETTCHER, BRENT THOMAS
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:BOETTCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF ANESTHESIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6104
Mailing Address - Fax:414-805-5195
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF ANESTHESIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6104
Practice Address - Fax:414-805-5195
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58704207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760781900Medicaid