Healthcare Provider Details

I. General information

NPI: 1902266273
Provider Name (Legal Business Name): CORNELIUS F BOERKOEL III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 S GRANGE AVE STE 510
SIOUX FALLS SD
57105-0410
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-7500
  • Fax: 605-328-7599
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number9765
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: