Healthcare Provider Details

I. General information

NPI: 1669815320
Provider Name (Legal Business Name): KEVIN HERBERT BOEGEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

420 DELAWARE ST SE DIAGNOSTIC RADIOLOGY, MMC 292
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-1000
  • Fax:
Mailing address:
  • Phone: 651-592-3931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number59081
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number59081
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: