Healthcare Provider Details

I. General information

NPI: 1194036368
Provider Name (Legal Business Name): ERIC RUSSELL KOTAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 S UNIVERSITY AVE
BEAVER DAM WI
53916-3027
US

IV. Provider business mailing address

100 MCINTOSH DR
BEAVER DAM WI
53916-9255
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-6606
  • Fax:
Mailing address:
  • Phone: 815-450-8972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301097060
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301097060
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: