Healthcare Provider Details

I. General information

NPI: 1346428802
Provider Name (Legal Business Name): ANDREW HARRY KOTSIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RENAISSANCE CTR SUITE R560
DETROIT MI
48243-1929
US

IV. Provider business mailing address

500 RENAISSANCE CTR SUITE R560
DETROIT MI
48243-1929
US

V. Phone/Fax

Practice location:
  • Phone: 313-473-3800
  • Fax: 313-396-5201
Mailing address:
  • Phone: 313-473-3800
  • Fax: 313-396-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101017496
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: