1225054695 NPI number — ERIK R BODTKER MD

Table of content: ERIK R BODTKER MD (NPI 1225054695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225054695 NPI number — ERIK R BODTKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BODTKER
Provider First Name:
ERIK
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225054695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3717 COTTAGE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59715-0664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-624-6329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 HIGHLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-6902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-461-3981
Provider Business Practice Location Address Fax Number:
801-733-5872
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  8414 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 071292 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01790452 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 134310888 . This is a "NEW WEST & HLTH CONNECT" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0148772 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1343108880000 . This is a "CHAMPUS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 67432514 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000091916 . This is a "BLUE CROSS OF MONTANA" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 1225054695 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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