Healthcare Provider Details

I. General information

NPI: 1376838698
Provider Name (Legal Business Name): G JAY ROTTMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

847 PARCHMENT SE DMI CLINIC
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

847 PARCHMENT SE DMI CLINIC
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-1466
  • Fax: 616-940-3006
Mailing address:
  • Phone: 616-940-1466
  • Fax: 616-940-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301024324
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: