Basic Information
| Provider Information | |||||||||
| NPI: | 1902822133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOERO | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | ALBERTO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153875511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153875511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 50054 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084S0012X | 50054 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 189446 | 01 | MO-BLUE SHIELD | OTHER | 208394601 | 05 | MO | MEDICAID |