Provider Demographics
NPI:1447246384
Name:BOETTGER, THOMAS (PT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BOETTGER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 DORSEY HALL DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7766
Mailing Address - Country:US
Mailing Address - Phone:410-730-9851
Mailing Address - Fax:410-730-9855
Practice Address - Street 1:4801 DORSEY HALL DR
Practice Address - Street 2:SUITE 130
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7766
Practice Address - Country:US
Practice Address - Phone:410-730-9851
Practice Address - Fax:410-730-9855
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19402208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD263996OtherMAMSI
MD6545-0002OtherBLUE CHOICE
MDK666-M571Medicare ID - Type UnspecifiedMEDICARE