Provider Demographics
NPI:1427062850
Name:ROTNICKI, RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:ROTNICKI
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 N DIVISION ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3122
Mailing Address - Country:US
Mailing Address - Phone:815-942-1550
Mailing Address - Fax:815-942-8419
Practice Address - Street 1:1715 N DIVISION ST STE A
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-3122
Practice Address - Country:US
Practice Address - Phone:815-942-1550
Practice Address - Fax:815-942-8419
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082778207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL100010274OtherRAILROAD MEDICARE
IL036082778Medicaid
ILF22483Medicare UPIN
K04635Medicare PIN