MEDICARE: MR. CONRAD CHRISTOPHER BOTZ II CST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZS0410X	Surgical Technologist

General Provider Information

NPI Number	:	1184983421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CONRAD CHRISTOPHER BOTZ II CST

Provider Business Mailing Address
First Line	:	1357 PHEASANT RUN
Second Line	:
City	:	NEW RICHMOND
State	:	WI
Zip	:	54017-4501
Country	:	US
Telephone Number	:	715-379-3882
Fax Number	:

Provider Business Practice Location Address
First Line	:	1357 PHEASANT RUN
Second Line	:
City	:	NEW RICHMOND
State	:	WI
Zip	:	54017-4501
Country	:	US
Telephone Number	:	715-379-3882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2012
Last Update Date	:	05/07/2012

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