=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275620155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT M BOTNICK PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 02/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9195 GRANT STREET #120 NORTH DENVER ORTHOPEDIC SPECIALISTS
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80229-4386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-453-2997
-----------------------------------------------------
Fax | 303-453-2998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4900 S MONACO ST STE 210
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80237-3486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-584-8000
-----------------------------------------------------
Fax | 303-584-8141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 44
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------