Basic Information
| Provider Information | |||||||||
| NPI: | 1174767776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTREMBA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486506301 | ||||||||
| FaxNumber: | 2486505486 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 W UNIVERSITY DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483071886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486506301 | ||||||||
| FaxNumber: | 2486505486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301101787 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.