Provider Demographics
NPI:1134325012
Name:BOETTCHER, ADAM KEITH (MD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:KEITH
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 1:1020 N SAN FRANCISCO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3281
Mailing Address - Country:US
Mailing Address - Phone:928-774-2300
Mailing Address - Fax:
Practice Address - Street 1:1020 N SAN FRANCISCO ST STE 200
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3281
Practice Address - Country:US
Practice Address - Phone:928-774-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ458962086S0122X
MI4301090356208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP707631Medicaid