Provider Demographics
NPI:1831142413
Name:BOETTCHER, ROGER MELVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:MELVIN
Last Name:BOETTCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7901
Mailing Address - Country:US
Mailing Address - Phone:320-532-3154
Mailing Address - Fax:320-532-3111
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:320-532-3111
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN340G8BOOtherBLUE CROSS CLINICS
MN01-21114OtherMEDICA ISLE CLINIC
MN01-21117OtherMEDICA HILLMAN CLINIC
MN340G9BOOtherBLUE CROSS HOSPITAL
MNNA9090253011OtherPREFERRED ONE
MN109558OtherUCARE
MN01-21010OtherMEDICA ONAMIA
MN206780300Medicaid
MNNA9090253011OtherPREFERRED ONE
MN080014154Medicare Oscar/Certification
MN340G9BOOtherBLUE CROSS HOSPITAL
MN340G8BOOtherBLUE CROSS CLINICS
MN01-21117OtherMEDICA HILLMAN CLINIC