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1558361246

NPI Code Detail

MEDICARE: DR. DOUGLAS LEE BOERTJE MD

MEDICARE: DR. DOUGLAS LEE BOERTJE MD

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	207PP0204X	Pediatric Emergency Medicine (Emergency Medicine) Physician	2006-01516	NC
2	207PP0204X	Pediatric Emergency Medicine (Emergency Medicine) Physician	36257	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558361246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS LEE BOERTJE MD

Provider Business Mailing Address
First Line	:	501 S SHARON AMITY RD STE 300
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-0035
Country	:	US
Telephone Number	:	704-377-2424
Fax Number	:	704-377-2687

Provider Business Practice Location Address
First Line	:	501 S SHARON AMITY RD STE 300
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-0035
Country	:	US
Telephone Number	:	704-377-2424
Fax Number	:	704-377-2687

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	08/23/2023

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Directions to “ DR. DOUGLAS LEE BOERTJE MD” Practice Location

Language	Start Address	Practice Location

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