Jacob Bottelberghe
Individual provider Active NPI Physician Assistant · Marshall, MN
NPI 1346894748 · NPPES record last updated Jul 25, 2019
Key facts
- NPI
- 1346894748
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- Practice address
- 300 S Bruce St
Marshall, MN 56258-1934 - Phone
- (507) 537-9165
- NPI assigned
- Jul 25, 2019
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 18
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 2019
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Avera Marshall
Practice addresses (Care Compare)
300 S Bruce St
Marshall, MN 56258-1934
Phone (507) 537-9165
Hospital & facility affiliations
- Avera Marshall Regional Medical Ctr
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20191125001728 | MN | Practitioner - Physician Assistant | 2961835368 | Reassigns benefits to 3 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 13159 | MN | MD | Physical Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Avera Marshall | Current |
Accepting new patients | |
| Avera Marshall | Current |
Accepting new patients | |
| Avera Tyler | Current |
Accepting new patients | |
| Avera Tyler | Current |
Accepting new patients | |
| Avera Marshall | Current |
Accepting new patients | |
| Granite Falls Municipal Hospital and Manor | Past | Accepting new patients |
Locations
300 S Bruce St
Marshall, MN 56258
Phone (507) 532-9631
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | Yes |
Addresses
Primary practice location
300 S Bruce St
Marshall, MN 56258-1934
Mailing address
1107 300TH St
Minneota, MN 56264-1103
Other providers in Marshall, MN
- Theresa Rose Bly
- Brian David Boersma
- Riley May Boese
- Kylie Linden Bossuyt
- Julijana Botic
- Janet Bottelberghe
- Victoria Ann Botten
- Danielle Brandt
- Robert Emerson Braun
- Shannon Lea Brewers
All providers in Marshall, MN · Physician Assistant in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 25, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.