Healthcare Provider Details

I. General information

NPI: 1043329964
Provider Name (Legal Business Name): RANDOLPH I ROTTENBILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 GOVT. CIRCLE BLACKFEET COMMUNITY HOSPITAL
BROWNING MT
59417
US

IV. Provider business mailing address

PO BOX 258
EAST GLACIER PARK MT
59434-0258
US

V. Phone/Fax

Practice location:
  • Phone: 406-338-6202
  • Fax: 406-338-2437
Mailing address:
  • Phone: 406-338-6202
  • Fax: 406-339-6237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5259
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: