Provider Demographics
NPI:1699772855
Name:ROTTMAN, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROTTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-751-2702
Mailing Address - Fax:586-751-1302
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-751-2702
Practice Address - Fax:586-751-1302
Is Sole Proprietor?:No
Enumeration Date:2005-07-02
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045798207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1653754Medicaid
MI700H273300OtherBCBSM
MIMR045798OtherBCBSM OTHER IDENTIFIER
MIMI4989085Medicare PIN
A77066Medicare UPIN