Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PP0204X | Pediatric Emergency Physician | 2006-01516 | NC |
N | 207PP0204X | Pediatric Emergency Physician | 36257 | TN |
NPI | 1558361246 |
---|---|
Provider Name | Dr. Douglas L Boertje |
First Address | Charlotte, NC 28211-0035 |
Second Address | Charlotte, NC 28211-0035 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2005 |
Last Update Date | 28/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
59-05661 | (05) | NC |
H65238 | (02) | TN |
N01517 | SC MEDICAID (01) | SC |