MEDICARE: DR. ALEXANDER VLADIMIROVICH OTELLIN MD

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	2084P0800X	Psychiatry Physician	22592	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740302066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXANDER VLADIMIROVICH OTELLIN MD

Provider Business Mailing Address
First Line	:	401 DIVISION ST STE 307
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-1455
Country	:	US
Telephone Number	:	304-932-4259
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 DIVISION ST STE 307
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-1455
Country	:	US
Telephone Number	:	304-932-4259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	09/17/2013

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