Basic Information
| Provider Information | |||||||||
| NPI: | 1194120493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOTTERER | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 860 EAST BROAD STREET | ||||||||
| Address2: | SUITE I | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440356542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403238515 | ||||||||
| FaxNumber: | 4403237900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1761 BEALL AVE | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446912342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302638100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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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 | 367500000X | RN-333220 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.