Healthcare Provider Details

I. General information

NPI: 1851881387
Provider Name (Legal Business Name): BRUCE GLENN ROTTMANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

324 GANNETT DR STE 200
SOUTH PORTLAND ME
04106-3266
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-0111
  • Fax:
Mailing address:
  • Phone: 207-482-7800
  • Fax: 207-482-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number24697
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberMD29365
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: