Provider Demographics
NPI:1609262161
Name:BOTTI, BRYAN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:ANDREW
Last Name:BOTTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRYAN
Other - Middle Name:
Other - Last Name:BOTTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3803 W CHESTER PIKE STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2336
Mailing Address - Country:US
Mailing Address - Phone:484-337-1530
Mailing Address - Fax:
Practice Address - Street 1:135 S BRYN MAWR AVE STE 200
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3129
Practice Address - Country:US
Practice Address - Phone:610-325-1390
Practice Address - Fax:610-325-1373
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD463061207Q00000X, 207QS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032587050002Medicaid