Provider Demographics
NPI:1194120493
Name:DOTTERER, MICHAEL (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DOTTERER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 EAST BROAD STREET
Mailing Address - Street 2:SUITE I
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6542
Mailing Address - Country:US
Mailing Address - Phone:440-323-8515
Mailing Address - Fax:440-323-7900
Practice Address - Street 1:1761 BEALL AVE
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2342
Practice Address - Country:US
Practice Address - Phone:330-263-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-333220367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered