Healthcare Provider Details

I. General information

NPI: 1437119872
Provider Name (Legal Business Name): ELLEN ROTBLATT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 03/16/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21700 NORTHWESTERN HWY FL 9
SOUTHFIELD MI
48075-4906
US

IV. Provider business mailing address

21700 NORTHWESTERN HWY FL 9
SOUTHFIELD MI
48075-4906
US

V. Phone/Fax

Practice location:
  • Phone: 855-445-4555
  • Fax:
Mailing address:
  • Phone: 855-445-4554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301052943
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: