Provider Demographics
NPI:1487655577
Name:ROTMAN, RICHARD K (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:K
Last Name:ROTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2379
Mailing Address - Country:US
Mailing Address - Phone:616-977-5852
Mailing Address - Fax:616-954-0659
Practice Address - Street 1:710 KENMOOR AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2379
Practice Address - Country:US
Practice Address - Phone:616-977-4852
Practice Address - Fax:616-954-0659
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035323174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI830001755OtherRR MEDICARE
MIM08620003Medicare PIN
MI830001755OtherRR MEDICARE