Provider Demographics
NPI:1528059375
Name:BECKERT, BORIS MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:BORIS
Middle Name:MICHAEL
Last Name:BECKERT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2406 W BROADWAY
Mailing Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL CENTER WEST BROADWAY, LLC
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1008
Mailing Address - Country:US
Mailing Address - Phone:502-775-1211
Mailing Address - Fax:502-775-1221
Practice Address - Street 1:600 W 98TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4773
Practice Address - Country:US
Practice Address - Phone:502-775-1211
Practice Address - Fax:502-775-1221
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2019-08-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI41127207Q00000X
MN35570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32020800Medicaid
MN766363300Medicaid
WI000656150Medicare PIN
MN080013981Medicare PIN
P00217517Medicare PIN
WI32020800Medicaid