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1699744227

NPI Code Detail

MEDICARE: DR. JODI RAE BOERGER WILDER LP

MEDICARE: DR. JODI RAE BOERGER WILDER LP

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	103TC0700X	Clinical Psychologist	LP4398	MN
2	103T00000X	Psychologist	LP4398	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HP37004	OTHER		HEALTH PARTNERS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	22522	OTHER	ND	BCBS OF ND
5	1032397	OTHER		PREFERRED ONE
6	310T1B0	OTHER	MN	BCBS BHST
7	171126	OTHER	MN	UCARE ALTRU
8	6159749	OTHER	MN	UBH MEDICA

General Provider Information

NPI Number	:	1699744227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JODI RAE BOERGER WILDER LP

Provider Business Mailing Address
First Line	:	PO BOX 5074
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57117-5074
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 WASHINGTON AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3905
Country	:	US
Telephone Number	:	218-846-2000
Fax Number	:	218-846-2114

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

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	03/08/2023

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Directions to “ DR. JODI RAE BOERGER WILDER LP” Practice Location

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