Healthcare Provider Details

I. General information

NPI: 1104355429
Provider Name (Legal Business Name): MARIE KOTENKO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIE IRVIN

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

IV. Provider business mailing address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

V. Phone/Fax

Practice location:
  • Phone: 561-548-3836
  • Fax:
Mailing address:
  • Phone: 561-548-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301112188
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberME146375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: