Provider Demographics
NPI:1588657779
Name:BOLTUCH, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BOLTUCH
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 1:3605 WARRENSVILLE CENTER ROAD
Mailing Address - Street 2:MSC 9152
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-286-6299
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:440-423-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350386882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0304914OtherBCMH
OH4230665OtherAETNA
OH735110OtherBUCKEYE
OH000000516213OtherANTHEM
OH000000221019OtherUNISON
OHP00405346OtherRAILROAD MEDICARE
OH0312852Medicaid
OH363371OtherWELLCARE
OH000000221019OtherUNISON
OH735110OtherBUCKEYE
OHA76411Medicare UPIN