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NPI Code Detail

MEDICARE: DR. FRED W ROTTNEK M.D.

MEDICARE: DR. FRED W ROTTNEK 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
1207Q00000XFamily Medicine Physician108515MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1588649271
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. FRED W ROTTNEK M.D.
Provider Business Mailing Address
First Line : 1402 S GRAND BLVD
Second Line : FAMILY AND COMMUNITY MEDICINE
City : SAINT LOUIS
State : MO
Zip : 63104-1004
Country : US
Telephone Number : 314-977-8489
Fax Number :
Provider Business Practice Location Address
First Line : 1402 S GRAND BLVD
Second Line : FAMILY AND COMMUNITY MEDICINE
City : SAINT LOUIS
State : MO
Zip : 63104-1004
Country : US
Telephone Number : 314-977-8489
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/14/2005
Last Update Date : 07/16/2015

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