1740275130 NPI number — KAROL L OTTEMAN DO

Table of content: KAROL L OTTEMAN DO (NPI 1740275130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740275130 NPI number — KAROL L OTTEMAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTEMAN
Provider First Name:
KAROL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740275130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30400 TELEGRAPH RD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-353-9460
Provider Business Mailing Address Fax Number:
248-353-8084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27780 NOVI RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48377-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-348-2400
Provider Business Practice Location Address Fax Number:
248-348-2991
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  5101010595 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11445733511 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121909 . This is a "CARECHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 144314 . This is a "GLHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 160F376930 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1656314934 . This is a "BCBS IND" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4506740 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C5951 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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