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NPI Code Detail

MEDICARE: DR. BRYAN KEITH BOTNER M.D.

MEDICARE: DR. BRYAN KEITH BOTNER M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12081S0010XSports Medicine (Physical Medicine & Rehabilitation) Physician29899KY
2208100000XPhysical Medicine & Rehabilitation PhysicianME119694FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
143105OTHERKYANTHEM BC AND BS

General Provider Information

NPI Number : 1134252349
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BRYAN KEITH BOTNER M.D.
Provider Business Mailing Address
First Line : 1801 LEE RD STE 165
Second Line :
City : WINTER PARK
State : FL
Zip : 32789-2127
Country : US
Telephone Number : 407-922-7691
Fax Number : 407-975-0407
Provider Business Practice Location Address
First Line : 1801 LEE RD STE 165
Second Line :
City : WINTER PARK
State : FL
Zip : 32789-2127
Country : US
Telephone Number : 407-922-7691
Fax Number : 407-975-0407
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/14/2007
Last Update Date : 03/04/2019

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