MEDICARE: COTTAB MEDICAL GROUP, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		MI

General Provider Information

NPI Number	:	1164529442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COTTAB MEDICAL GROUP, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 36958
Second Line	:
City	:	GROSSE POINTE
State	:	MI
Zip	:	48236-0958
Country	:	US
Telephone Number	:	313-369-5765
Fax Number	:

Provider Business Practice Location Address
First Line	:	4777 E OUTER DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-3241
Country	:	US
Telephone Number	:	313-369-5700
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PATRICK CHARLES
Credential	:	M.D.
Telephone Number	:	313-369-5765

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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