Healthcare Provider Details

I. General information

NPI: 1194120493
Provider Name (Legal Business Name): MICHAEL DOTTERER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 BEALL AVE
WOOSTER OH
44691-2342
US

IV. Provider business mailing address

860 EAST BROAD STREET SUITE I
ELYRIA OH
44035-6542
US

V. Phone/Fax

Practice location:
  • Phone: 330-263-8100
  • Fax:
Mailing address:
  • Phone: 440-323-8515
  • Fax: 440-323-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN-333220
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: