Healthcare Provider Details

I. General information

NPI: 1174767776
Provider Name (Legal Business Name): JOHN A OTREMBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 W UNIVERSITY DR SUITE 250
ROCHESTER MI
48307-1886
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400-CREDENTIALING
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 248-650-6301
  • Fax: 248-650-5486
Mailing address:
  • Phone: 248-650-6301
  • Fax: 248-650-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301101787
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: