Provider Demographics
NPI:1700817061
Name:BOTHWELL, MICHAEL F (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:BOTHWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BYRAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5905
Mailing Address - Country:US
Mailing Address - Phone:203-532-5000
Mailing Address - Fax:203-532-5000
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-5900
Practice Address - Fax:718-579-4620
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000720363A00000X
NY006244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS55436Medicare UPIN
CT970000622Medicare ID - Type Unspecified