Provider Demographics
NPI:1780673921
Name:BOTTNER, RANDY KYLE (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:KYLE
Last Name:BOTTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5701
Mailing Address - Country:US
Mailing Address - Phone:912-352-8700
Mailing Address - Fax:912-650-6805
Practice Address - Street 1:6301 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5701
Practice Address - Country:US
Practice Address - Phone:912-352-8700
Practice Address - Fax:912-650-6805
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035381207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00495855JMedicaid
GA000495855AMedicaid
SCSC5330E470Medicare PIN
GAE38061Medicare UPIN
GA06BDCBNMedicare PIN